Radial Head Subluxation

(Pulled Elbow, Nursemaids Elbow)

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Definition

-  Subluxation of the radial head into the radiohumeral joint

 

Features

-  Most common elbow injury in chidren

-  Typically 1-4yrs old

-  Girls > boys

-  Left > right

-  Clinical Dx

 

Associated S/S

-  Little distress but pain++ on movement

-  Esp supination

-  +/- tender radial head

-  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

-  Swinging child by forearms

-  Falling onto elbow

-  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

-   Grip childs forearm & hyperpronate forearm

-   +/- audible click

-  Supination/Flexion

-   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

-  +/- reuse of arm by 10-15min

-   May be reluctant initially

-   May distract w object to grasp..

-  Recurrence 25-40%

-  Failed reduction

-   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