Radial Head Subluxation
(Pulled Elbow, Nursemaids
Elbow)
Definition
-
Subluxation of the radial head into the radiohumeral joint
Features
-
Most common elbow injury in chidren
-
Typically 1-4yrs old
-
Girls > boys
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Left > right
-
Clinical Dx
Associated S/S
-
Little distress but pain++ on movement
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Esp supination
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+/- tender radial head
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Normal passive ROM if assessable
-
Non-use of effected arm
-
Arm held close to body w full elbow extension or slight flexion w
pronation
-
50% pts clear Hx of pull injury
-
Must examine entire upper extremity
incl clavicle
Mechanism
-
Axial traction of pronated forearm w elbow extension
-
Annular ligament slips over radial head
-
Radial head slips into radiohumeral joint
Causes
-
Grabbing childs arm to prevent from running away or falling
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Swinging child by forearms
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Falling onto elbow
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Minor direct trauma to elbow
-
< 6months old rolling over in bed
DDx
-
Congenital dislocation of radial head
-
Monteggia fracture: subluxation + ulnar shaft fracture
Ix
-
Clinical Dx: mechanism & posturing
-
+/- elbow X-ray
-
Exclude fracture or dislocation
Mx
-
Analgesia usually not required
-
Reduction
-
Generally easy to reduce
-
Hyperpronation
-
Support childs arm at elbow
-
Moderate pressure w finger at radial head
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Grip childs forearm & hyperpronate forearm
-
+/- audible click
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Supination/Flexion
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Supports childs arm at elbow
-
Moderate pressure w finger at radial head
-
Grip childs forearm w mild traction
-
Fully supinate forearm & fully flex elbow w mild traction
-
+/- audible click
-
Immediate relief post successful reduction
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+/- reuse of arm by 10-15min
-
May be reluctant initially
-
May distract w object to grasp..
-
Recurrence 25-40%
-
Failed reduction
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If several attempts --> x-ray
-
Normal x-ray + unsuccessful --> orthopaedics
-
+/- Cast
-
If reduction delayed >12hrs: long arm back slab w 90o flexion + full
supination 10 days
-
If x3 recurrent episodes cast as above for 3 weeks
References
Upto Date: Radial Head
Subluxation 22/09/10
Wheeless Textbook of Orthopaedics:
www.wheelessonline.com/ortho/nursemaids_elbow_radial_head_subluxation
Pic (reduction):
reference.medscape.com/features/slideshow/irritable-child
Pic
(mechanism):pediatrics.aappublications.org/content/110/1/171.full