Nursemaid’s elbow or something more? A clinical case

Abstract

Introduction: Subluxation of the radius head (also known as nursemaid’s elbow) is a common diagnosis. Although it is clinical, it is important to exclude other rare causes.

Case description: A healthy two-year-old male child was brought to the family physician (FP) for sudden pain in the right elbow in the last four days, without any history of trauma. Objectively, the pain was present on palpation and mobilization of the elbow, with an antalgic position in flexion and adduction of the elbow. He was referred to the emergency department (ED), where the flexion-supination maneuver was performed. At discharge, the child presented with complete and active limb mobility, and analgesia was prescribed. After 10 days, he remained in pain and defensive to mobilization, without local inflammatory signs. After further observation by FP, he was referred to the ED, where he underwent imaging and analytical studies. The imaging study detected the presence of a lytic lesion in the cubital bone with cortical expansion and loss of its delimitation. These clinical findings assumed the diagnosis of Langerhans cell histiocytosis (LCH) – eosinophil granuloma (EG).

Comment: The initial diagnostic impression was directed to the most likely hypothesis. In the diagnostic gait, an unlikely diagnosis was revealed: LCH. FP's diagnostic approach and decision-making are determined by the prevalence and incidence of the disease in the community. It emphasizes that the persistence of symptoms should promote a more detailed investigation, considering the differential diagnoses.