Radial head subluxation (commonly referred to as pulled elbow or nursemaid elbow) refers to the partial dislocation of the head of the radius at the level of the radio-humeral joint. The injury most commonly occurs in young children after sudden tugging of the outstretched and pronated arm (e.g., if an adult suddenly pulls a child's arm to prevent them from falling). Clinical signs include painful and limited movement of the upper extremity and guarding, with the arm held in a flexed and pronated position. Diagnosis is usually clinical, based on classic history and examination findings. Imaging is reserved for cases of diagnostic uncertainty or if treatment is unsuccessful. Management is usually conservative and involves closed manual reduction of the radial head. The reduction can be carried out in an outpatient setting and does not require any immobilization of the elbow or further surgical treatment. Radial head fractures can cause hemarthrosis, which may be the only visible sign on the elbow x-ray. Most radial head fractures are treated conservatively, with only complex fractures managed surgically.
- Sex: ♀ > ♂ 
- Risk factors
Epidemiological data refers to the US, unless otherwise specified.
- Traumatic (most common)
- Congenital structural abnormalities: e.g., collagen abnormalities, abnormal endochondral ossification of the growth plate and ossification sites external to the joint 
- Child holds the arm, with the elbow extended or slightly flexed and pronated. 
- Pain, aggravated by movement 
- Reduced range of movement (ROM) with limited extension and flexion
- No swelling
- History and findings may be atypical, especially with children < 3 years of age, who may be unable to properly articulate their symptoms or the circumstances of the injury. 
- Assess the child's entire arm and clavicle.
- Classic : Proceed directly to treatment.
- Diagnostic uncertainty or unsuccessful reduction
- Obtain imaging to rule out .
- Unsuccessful reduction but imaging supports the diagnosis:
- Immobilize the arm.
- Refer to orthopedic surgery for evaluation within 2 days.
Closed manual reduction 
- Neither anesthesia nor sedation is required.
- Apply pressure to the radial head and perform one of the following maneuvers: 
- A pop or click may be felt or heard.
- Leave the room, ensuring there are toys for the child to play with, and reassess after 10–30 minutes. 
- Following successful reduction, the child should have full, pain-free ROM.
- Neither follow-up nor modifications to normal activity are required.
- Educate caregivers on how to prevent a recurrence. 
- Patients with recurrent subluxations: Consider arm immobilization. 
Imaging is not routinely performed before or after reduction in patients with classic . Imaging (typically x-ray) is usually only performed in cases of diagnostic uncertainty or unsuccessful reduction.
- Often normal
- May show displacement of the radiocapitellar line (not sensitive or specific) 
- Ultrasound: Findings may include the following.
- MRI: may be used in atypical cases 
Radial head subluxation is not typically associated with swelling, deformity, or vascular or neurological compromise; if present, obtain imaging to exclude differential diagnoses of radial head subluxation. 
- Elbow fractures
- Elbow dislocation
- Soft tissue injury
- Very young children may be unable to articulate the site of pain; the injury could be anywhere from the clavicle to the hand.
Radial head fracture
- Epidemiology: more common in adults than radial head dislocation or subluxation 
- Clinical evaluation 
- Diagnostics: x-ray elbow (AP, lateral and oblique) 
- Assess for . 
- Provide acute pain management. 
Nondisplaced fractures are treated conservatively.
- Immobilize in a sling or 24–72 hours.  for
- Start early exercises. 
- Complex fractures are typically treated surgically. 
- Disposition: typically outpatient management with prompt orthopedic follow-up 
Treat a positive fat pad sign with corresponding bony tenderness as an occult fracture. 
The differential diagnoses listed here are not exhaustive.