Radial Head Subluxation: Factors Associated with Its Recurrence and Radiographic Evaluation in a Tertiary Pediatric Emergency Department.

BACKGROUND: Radial head subluxation (RHS) is a common complaint seen in the pediatric emergency department in children ages 6 months to 4 years. Classically, injury occurs due to axial traction on the arm, but this mechanism is not universal. Some patients will have recurrent RHS; some may undergo x-ray (XR) evaluation for alternative diagnosis. OBJECTIVES: To determine factors associated with recurrences and radiographic evaluations in RHS. METHODS: A retrospective study with inclusion criteria: under 10 years of age with discharge diagnosis "nursemaid," "radial head," or "subluxation." We examined factors associated with RHS recurrences, circumstances when radiographic evaluations performed, physician's training background (pediatric vs. general emergency medicine), mechanisms of injury, and demographic factors including age, gender, and arm involved. RESULTS: In 246 visits, median age was 27 months (interquartile range 16.1), with females comprising 55.7% (n = 137), and left-sided predominance (52%, n = 130). Mechanisms of injury were classified as "pull" (65.9%, n = 162), "non-pull" (15.9%, n = 39), and "unknown" (18.3%, n = 45). Eighteen patients with recurring RHS were more likely to be male (p = 0.008). In 61 visits where radiography was performed, patients were older (p = 0.03), with a higher frequency seen in non-pull and unknown mechanism (p = 0.0001). No significant difference was found in frequency of radiographs obtained in regard to physician training (p = 0.4660). CONCLUSION: RHS can result from a myriad of mechanisms. We found that recurrence was more likely in male patients. Factors associated with radiographic evaluation included atypical mechanism, older age, and unclear history, regardless of physician training background.

Prednisone for emergency department low back pain: a randomized controlled trial.

BACKGROUND: Although oral corticosteroids are commonly given to emergency department (ED) patients with musculoskeletal low back pain (LBP), there is little evidence of benefit. OBJECTIVE: To determine if a short course of oral corticosteroids benefits LBP ED patients. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Suburban New Jersey ED with 80,000 annual visits. PARTICIPANTS: 18-55-year-olds with moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2 days prior to presentation. Exclusion criteria were suspected nonmusculoskeletal etiology, direct trauma, motor deficits, and local occupational medicine program visits. PROTOCOL: At ED discharge, patients were randomized to either 50 mg prednisone daily for 5 days or identical-appearing placebo. Patients were contacted after 5 days to assess pain on a 0-3 scale (none, mild, moderate, severe) as well as functional status. RESULTS: The prednisone and placebo groups had similar demographics and initial and discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to follow-up, leaving 32 and 35 patients in the prednisone and placebo arms, respectively. At follow-up, the two arms had similar pain on the 0-3 scale (absolute difference 0.2, 95% confidence interval [CI] -0.2, 0.6) and no statistically significant differences in resuming normal activities, returning to work, or days lost from work. More patients in the prednisone than in the placebo group sought additional medical treatment (40% vs. 18%, respectively, difference 22%, 95% CI 0, 43%). CONCLUSION: We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal LBP.