Radial head subluxation

Last updated: August 16, 2022

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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.

Epidemiological data refers to the US, unless otherwise specified.

  • Traumatic (most common)
    • Sudden axial traction of the pronated and extended forearm [5]
    • 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 (hence the term “nursemaid's elbow”) [3][8]
  • Congenital structural abnormalities: e.g., collagen abnormalities, abnormal endochondral ossification of the growth plate and ossification sites external to the joint [9]

  • Child holds the arm, with the elbow extended or slightly flexed and pronated. [5]
  • Pain, aggravated by movement [5]
  • 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. [1]

Approach [3][5]

Radial head subluxation is typically a clinical diagnosis; a classic history and examination and successful closed manual reduction confirm the diagnosis. Imaging is not usually required. [3]

Closed manual reduction [3][10]

  • Neither anesthesia nor sedation is required.
  • Apply pressure to the radial head and perform one of the following maneuvers: [11]
    • Hyperpronation maneuver: Hyperpronate the forearm (with the elbow extended or flexed at 90 degrees). [12]
    • Supination-flexion maneuver: Supinate the forearm, then immediately flex the elbow.
  • 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. [5]
  • Following successful reduction, the child should have full, pain-free ROM.

Postreduction care

  • Neither follow-up nor modifications to normal activity are required.
  • Educate caregivers on how to prevent a recurrence. [3][5]
  • Patients with recurrent subluxations: Consider arm immobilization. [3]

Imaging [3][5]

Imaging is not routinely performed before or after reduction in patients with classic clinical features of radial head subluxation. Imaging (typically x-ray) is usually only performed in cases of diagnostic uncertainty or unsuccessful reduction.

X-ray elbow (AP and lateral) [3][5]

Other modalities

  • Ultrasound: Findings may include the following.
    • Widened space between the radial head and capitellum
    • Displacement of the annular ligament
    • Hook sign [3][15]
  • MRI: may be used in atypical cases [1]

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. [3]

Radial head fracture

The differential diagnoses listed here are not exhaustive.

  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): p.20-2.
  2. Choung W, Heinrich SD. Acute annular ligament interposition into the radiocapitellar joint in children (nursemaid's elbow). Journal of Pediatric Orthopaedics. 1995; 15 (4): p.454-6.
  3. Gottlieb M, Suleiman LI. Current Approach to the Management of Forearm and Elbow Dislocations in Children. Pediatr Emerg Care. 2019; 35 (4): p.293-298. doi: 10.1097/pec.0000000000001805 . | Open in Read by QxMD
  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): p.554-7.
  5. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  6. Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Annals of Emergency Medicine. 1990; 19 (9): p.1019-23.
  7. Illingworth CM. Pulled elbow: a study of 100 patients. BMJ. 1975; 2 (5972): p.672-4.
  8. Rodts MF. Nursemaid's elbow: a preventable pediatric injury. Orthopaedic Nursing. 2009; 28 (4): p.163-6.
  9. Al-qattan MM, Abou al-shaar H, Alkattan WM. The pathogenesis of congenital radial head dislocation/subluxation. Gene. 2016; 586 (1): p.69-76.
  10. Pappas N, Bernstein J. Fractures in Brief: Radial Head Fractures. Clin Orthop Relat Res. 2010; 468 (3): p.914-916. doi: 10.1007/s11999-009-1183-1 . | Open in Read by QxMD
  11. de Muinck Keizer RJO, Walenkamp MMJ, Goslings JC, Schep NWL. Mason Type I Fractures of the Radial Head. Orthopedics. 2015; 38 (12). doi: 10.3928/01477447-20151123-06 . | Open in Read by QxMD
  12. Blaney SM, Giardino AP, Orange JS, et al.. Rudolph's Pediatrics, 23rd Edition. McGraw-Hill Education / Medical ; 2018
  13. Rens Bexkens, Frederic J. Washburn, Denise Eygendaal, Michel P.J. van den Bekerom, Luke S. Oh. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis. Am J Emerg Med. 2017; 35 (1): p.159-163. doi: 10.1016/j.ajem.2016.10.059 . | Open in Read by QxMD
  14. Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2017; 2017 (7). doi: 10.1002/14651858.cd007759.pub4 . | Open in Read by QxMD
  15. Hanes L, McLaughlin R, Ornstein AE. Suspected Radial Head Subluxation in Infants. Pediatr Emerg Care. 2019; 37 (1): p.e58-e59. doi: 10.1097/pec.0000000000001848 . | Open in Read by QxMD
  16. Kunkel S, Cornwall R, Little K, Jain V, Mehlman C, Tamai J. Limitations of the Radiocapitellar Line for Assessment of Pediatric Elbow Radiographs. J Pediatr Orthop. 2011; 31 (6): p.628-632. doi: 10.1097/bpo.0b013e3182210988 . | Open in Read by QxMD
  17. Sohn Y, Lee Y, Oh Y, Lee W.. Sonographic finding of a pulled elbow: the "hook sign". Pediatr Emerg Care. 2014; 30 (12): p.919-21.

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