Radial Head Subluxation Diagnosis and Management

in the Emergency

DepartmentPaul Jones, PGY3

Anatomy of Radial Head Subluxation History Physical Classic vs Non Classic Diagnosis Radiologic Findings Treatment – Reduction Techniques Follow up

Objectives

What is the best method for reducing radial head subluxation (RHS)?

Question

Anatomy

Recurrent nursemaid's elbow (annular ligament displacement) treatment via telephone. Kaplan RE, Lillis KA. Pediatrics. 2002 Jul;110(1 Pt 1):171-4. PMID: 12093966

MOI: pull, fall, spin

Classification has been proposed as traction, non traction traumatic and not classified.

No longer a "nursemaid's" elbow: mechanisms, caregivers, and prevention. Rudloe TF, Schutzman S, Lee LK, Kimia AA. Pediatr Emerg Care. 2012 Aug;28(8):771-4. doi: 10.1097/PEC.0b013e3182624906. PMID: 22858743

History

Look for deformity, bruising, swelling, check

rom, motor and sensation.  Pain, irritability, lack of use of the arm. 

Physical

Most common MSK injury in children

between ages 2 and 5.    A sudden pull on a protonated,

extended arm of a child up to 5 years of age is followed by a refusal to use the arm. 

Diagnosis

Typical history is a traction mechanism, age 2-

5, pain, decreased use of arm, absence of deformity.

Classically

All patients were in minimal distress, holding their affected arms semiflexed and pronated (the nursemaid's position).

This study suggests that even in the absence of the classic history of upper extremity traction, radial head subluxation should be suspected in any pediatric patient with an upper extremity complaint who presents with the affected arm in the nursemaid's position. 

Nonclassic history in children with radial head subluxations. Sacchetti A, Ramoska EE, Glascow C. J Emerg Med. 1990 Mar-Apr;8(2):151-3. PMID: 2362116

Semiflexed and pronated

Radiographs are said to be normal. Main differential is epiphyseal rotation. If

concerned take early matched views of both elbows.

Radiographic changes with radial head subluxation in children. Snyder HS. Emerg Med. 1990 May-Jun;8(3):265-9. Erratum in: J Emerg Med 1990 Nov-Dec;8(6):775, 805. PMID: 2373834

Radiologic 

Successful reduction was accomplished in 121 (80.7%)

of patients during first attempt, in 56 (68.3%) of the patients using the SF technique and in 65 (95.6%) of patients using the HP technique (P<.001).  In the end they found SF (59/84) was less successful than HP (91/93). The pain levels of both techniques was not statistically different.

HP requires fewer attempts at reduction compared to supination!

(Ref 1, 3, 6, 12 & 13)

Treatment

http://www.youtube.com/watch?v=tJb5rGOFiTY

Video

Reduction by a family member?

Recurrent subluxation -> case reports of teaching non medical personnel to reduce the radial head over the phone.

Recurrent nursemaid's elbow (annular ligament displacement) treatment via telephone. Kaplan RE, Lillis KA. Pediatrics. 2002 Jul;110(1 Pt 1):171-4. PMID: 12093966

Reduction by a family member?

None required if simple reduction and child

begins using arm again post reduction.

Follow Up

One Canadian series of 501 cases of RHS in 427 children over a 2-year period at

CHEO The mean age was 2.4 years (range 22 d-9.7 yr) Injury was caused by a pull in 314 (62.8%) cases, a fall in 91 (18.2%) cases and a

twist in 20 (4.0%) of the cases. The median time from triage to physician assessment was 1.3 hours, with 112

(23.5%) patients waiting > 2 hours and 33 (6.9%) waiting > 3 hours. The median time from triage to ED discharge was 1.7 hours, with 193 (41.2%)

staying > 2 hours, 85 (18.1%) staying > 3 hours and 30 (6.4%) staying > 4 hours. Overall, 490 (99.2%) of these injuries were reduced in the ED: 98 (19.8%) were

reduced prior to physician assessment and 309 (89.6%) were reduced on the first attempt.

The technique used was pronation in 138 (52.7%), supination in 100 (38.2%), and pronation and supination in 24 (9.2%) cases.

Radial head subluxation: how long do children wait in the emergency department before reduction? Toupin P, Osmond MH, Correll R, Plint A. CJEM. 2007 Sep;9(5):333-7. PMID: 17935648

Worth considering…

1. Is pronation less painful and more effective than supination for reduction of a radial head subluxation? Potis T,

Merrill H. Ann Emerg Med. 2013 Mar;61(3):291-2. doi: 10.1016/j.annemergmed.2012.10.024. Epub 2012 Nov 30. Review. No abstract available. PMID: 23207067 

2. No longer a "nursemaid's" elbow: mechanisms, caregivers, and prevention. Rudloe TF, Schutzman S, Lee LK, Kimia AA. Pediatr Emerg Care. 2012 Aug;28(8):771-4. doi: 10.1097/PEC.0b013e3182624906. PMID: 22858743

3. Manipulative interventions for reducing pulled elbow in young children. Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW. Cochrane Database Syst Rev. 2012 Jan 18;1:CD007759. doi: 10.1002/14651858.CD007759.pub3. Review. PMID: 22258973

4. Radial head subluxation: how long do children wait in the emergency department before reduction? Toupin P, Osmond MH, Correll R, Plint A. CJEM. 2007 Sep;9(5):333-7. PMID: 17935648

5. Recurrent nursemaid's elbow (annular ligament displacement) treatment via telephone. Kaplan RE, Lillis KA. Pediatrics. 2002 Jul;110(1 Pt 1):171-4. PMID: 12093966

6. Radial head subluxation: comparing two methods of reduction. McDonald J, Whitelaw C, Goldsmith LJ. Acad Emerg Med. 1999 Jul;6(7):715-8. PMID: 10433531

7. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Macias CG, Bothner J, Wiebe R. Pediatrics. 1998 Jul;102(1):e10. PMID: 9651462

8. Pulled elbow in childhood. Bretland PM. Br J Radiol. 1994 Dec;67(804):1176-85. Review. PMID: 7874416 9. Nonclassic history in children with radial head subluxations. Sacchetti A, Ramoska EE, Glascow C. J Emerg Med.

1990 Mar-Apr;8(2):151-3. PMID: 236211610. Radiographic changes with radial head subluxation in children. Snyder HS. Emerg Med. 1990 May-Jun;8(3):265-

9. Erratum in: J Emerg Med 1990 Nov-Dec;8(6):775, 805. PMID: 237383411. Radial head subluxation. David ML. Am Fam Physician. 1987 Apr;35(4):143-6. PMID: 356521612. Pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial. Bek D,

Yildiz C, Köse O, Sehirlioğlu A, Başbozkurt M. Eur J Emerg Med. 2009 Jun;16(3):135-8. doi: 10.1097/MEJ.0b013e32831d796a. PMID: 19262394

13. Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid's elbow cases. Gunaydin YK, Katirci Y, Duymaz H, Vural K, Halhalli HC, Akcil M, Coskun F. Am J Emerg Med. 2013 Jul;31(7):1078-81. doi: 10.1016/j.ajem.2013.04.006. Epub 2013 May 20. PMID: 23702058

References