• Clinical science

Radial head subluxation (Nursemaid's elbow…)

Abstract

Radial head subluxation (also “pulled elbow” or “nursemaid's 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., adults suddenly pulling a child's arm to keep it 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. The diagnosis is often made based on typical symptoms and therefore x-ray imaging is generally not required. 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.

Definition

Epidemiology

  • Radial head subluxation is the most common elbow injury in children under 5 years of age and occurs exclusively in this age group. [2]
  • Age: 1–5 years, peak incidence between two and three years.[3][4]
  • Sex: > [5][4]
  • Risk factors

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Traumatic (most common)
    • Sudden axial traction of the pronated and extended forearm[6]
    • Typical activities: adult quickly pulls up a falling child by the hand; , swings a child by the hands, or drags a child by the arm[7][8]
  • Congenital structural abnormalities (e.g., collagen abnormalities, abnormal endochondral ossification of the growth plate and ossification sites external to the joint)[9]

Clinical features

  • Child holds the arm, with the elbow slightly flexed and pronated[2]
  • Pain, aggravated by movement[2]
  • Limited extension and flexion
  • No swelling
  • History and findings may be atypical, especially with children < 3 years old, who may be unable to properly articulate their symptoms or the circumstances of the injury[1]

Diagnostics

The condition is predominantly clinically diagnosed, with a limited role for imaging. A successfully executed closed manual reduction is not just therapeutic, but also diagnostic (see “Therapy” below).

  • X-ray
    • Not necessary, if the patient presents with typical history and clinical signs.[10]
    • May be useful in atypical or irreducible cases to identify a displacement of the radiocapitellar line without further disruption of the radiocapitellar joint[11]
  • Ultrasound: may be considered to prevent misdiagnosis and delayed treatment[12] in children too young to properly articulate their symptoms, like those < 2 years.
  • MRI: may be considered in atypical cases or where congenital structural anomalies are suspected

Differential diagnoses

Radial head fracture

  • Etiology
    • Fall on outstretched hand with the elbow partially flexed and pronated[13]
    • Stress fracture (e.g., in throwing sports)
  • Epidemiology: occurs more commonly in adults than radial head dislocation or subluxation[14]
  • Clinical presentation[13]
    • Radial head region is tender to touch
    • Pronation and supination of the forearm is painful
    • Effusion or hemarthrosis of the elbow joint may be present .
  • Diagnostic: Elbow x-ray in two planes may show typical “fat pad sign”[14]
  • Treatment
    • Nondisplaced fractures are treated conservatively with a plaster splint for approx. 2 weeks[15].
    • Complex fractures are treated surgically [13][14]
  • Complication: incorrect reduction can lead to cubitus valgus

The differential diagnoses listed here are not exhaustive.

Treatment

  • Reduction maneuvers
    • While applying pressure to the radial head, the following maneuvers are carried out:[16][17]
      • Supination of the forearm with the elbow in slight flexion
      • Hyperpronation of the forearm
    • In successful reduction, a “click” might be heard[5]
    • Post-reduction: clinical control of normal range of motion of the elbow[5][18]
    • A second attempt at reduction may be necessary (by using the same or a different approach), if normal range of motion is not achieved[16]
    • Immobilization of the arm is not required. Most children regain full mobility of the elbow in a short time (10-30 minutes post reduction)[5][18].
  • Surgery: only indicated when closed manipulative reduction is unsuccessful[19]
  • Prevention: parents and caretakers should be educated about the most common mechanisms of injury to prevent recurrence[7]
  • 1. Richardson M, Kuester VG, Hoover K. The usefulness of MRI in atypical pulled/nursemaid's elbow: a case report. Journal of Pediatric Orthopaedics . 2012; 32(5): pp. 20–2. pmid: 22706475.
  • 2. Gilbert Lam, Edited by: Anne Marie Jekyll, MD. ELBOW INJURIES . http://learn.pediatrics.ubc.ca/body-systems/musculoskeletal-system/elbow-injuries/. Updated November 10, 2011. Accessed December 14, 2016.
  • 3. Illingworth CM. Pulled elbow: a study of 100 patients. BMJ. 1975; 2(5972): pp. 672–4. pmid: 1139174.
  • 4. Vitello S, Dvorkin R, Sattler S, Levy D, Ung L. Epidemiology of nursemaid's elbow. The Western Journal of Emergency Medicine. 2014; 15(4): pp. 554–7. pmid: 25035767.
  • 5. Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Annals of Emergency Medicine. 1990; 19(9): pp. 1019–23. pmid: 2393168.
  • 6. Woo CC. Traumatic radial head subluxation in young children: a case report and literature review. Journal of Manipulative and Physiological Therapeutics. 1987; 10(4): pp. 191–200. pmid: 3655567.
  • 7. Rodts MF. Nursemaid's elbow: a preventable pediatric injury. Orthopaedic Nursing. 2009; 28(4): pp. 163–6. pmid: 19657259.
  • 8. Kunkler CE. Did you check your nursemaid's elbow?. Orthopaedic Nursing. 2000; 19(4): pp. 49–52. pmid: 11153321.
  • 9. Al-qattan MM, Abou al-shaar H, Alkattan WM. The pathogenesis of congenital radial head dislocation/subluxation. Gene. 2016; 586(1): pp. 69–76. pmid: 27050104.
  • 10. Choung W, Heinrich SD. Acute annular ligament interposition into the radiocapitellar joint in children (nursemaid's elbow). Journal of Pediatric Orthopaedics. 1995; 15(4): pp. 454–6. pmid: 7560033.
  • 11. Snyder HS. Radiographic changes with radial head subluxation in children. The Journal of Emergency Medicine. 1990; 8(3): pp. 265–269. doi: 10.1016/0736-4679(90)90003-E.
  • 12. Sohn Y, Lee Y, Oh Y, Lee W. Sonographic finding of a pulled elbow: the "hook sign". Pediatr Emerg Care. 2014; 30(12): pp. 919–21. pmid: 25469607.
  • 13. Kaas L. Radial head fracture: a potentially complex injury. url: https://pure.uva.nl/ws/files/1609359/104455_05.pdf Accessed December 14, 2016.
  • 14. Wheeless CR III. Radial Head Frx . http://www.wheelessonline.com/ortho/radial_head_frx. Updated October 17, 2016. Accessed December 14, 2016.
  • 15. Wheeless CR III. Type I Radial Head Fracture. http://www.wheelessonline.com/ortho/type_i_radial_head_fracture. Updated January 8, 2016. Accessed March 6, 2017.
  • 16. Bek D, Yildiz C, Köse O, Sehirlioğlu A, Başbozkurt M. Pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial. European Journal of Emergency Medicine . 2009; 16(3): pp. 135–8. pmid: 19262394.
  • 17. Guzel M, Salt O, Demir MT, Akdemir HU, Durukan P, Yalcin A. Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation. Nigerian Journal of Clinical Practice. 2014; 17(2): pp. 201–4. pmid: 24553032.
  • 18. Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. THE AMERICAN JOURNAL OF DISEASES OF CHILDREN. 1985; 139(12): pp. 1194–7. pmid: 4061421.
  • 19. Corella F, Horna L, Villa A, González JL, Soleto J. Irreducible 'ulled elbow' report of two cases and review of the literature. Journal of Pediatric Orthopaedics B. 2010; 19(4): pp. 304–6. pmid: 20549851.
  • Müller M. Chirurgie für Studium und Praxis (2012/13). Medizinische Verlags- und Informationsdienste; 2011.
  • Steen K. [Subluxation of the radial head]. Journal of the Norwegian Medical Association. 2000; 120(11): pp. 1323–5. pmid: 10868095.
last updated 11/09/2017
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