Radial Head SubluxationRadial Head Subluxation Common injury that is seen most often Common injury that is seen most often

in children between the ages of 1-6 in children between the ages of 1-6 yearsyears

Occurs when longitudinal traction is Occurs when longitudinal traction is placed on the hand while the elbow is placed on the hand while the elbow is extended and the forearm pronated.extended and the forearm pronated.

Usually occurs when child falls and Usually occurs when child falls and continues to be held by the hand, or continues to be held by the hand, or when small children are swung by when small children are swung by their arms.their arms.

AnatomyAnatomy

The annular ligament normallypasses around the proximal radius just below the radial head. With traction on the extended arm, the annular ligament slides over the head of the radius into the joint space and becomes entrapped Common early childhood injury Common early childhood injury because at an early age, the because at an early age, the radial head is spherical and is radial head is spherical and is composed mainly of cartilagecomposed mainly of cartilage

Clinical PresentationClinical Presentation history of arm being pulledhistory of arm being pulled injured elbow pronated, partially injured elbow pronated, partially

flexed and held by side, child will not flexed and held by side, child will not use the limb.use the limb.

there is anterolateral tenderness over there is anterolateral tenderness over the radial headthe radial head

no swelling, redness, warmth, no swelling, redness, warmth, abrasions, or ecchymosisabrasions, or ecchymosis

have been reports of infants < 6 have been reports of infants < 6 months old with a history of not using months old with a history of not using arm after rolling over.arm after rolling over.

normal partial subluxation dislocationsubluxation

traction

Imaging Studies

Diagnosis is by history and physical Diagnosis is by history and physical examination. examination. Imaging studies are useful in ruling out possible fracture but are often unnecessary,and are normal in most and are normal in most instances. instances.

If x-rays are taken, often the subluxation is If x-rays are taken, often the subluxation is reduced when the technician positions the reduced when the technician positions the arm on the plate.arm on the plate.

Radiographs become necessary if pain Radiographs become necessary if pain continues post-reduction.continues post-reduction.

Ultrasonography has been used as a noninvasive modality to assess for annular ligamentous injury and displacement of the radial head from the capitellum. It has also been used to assess progress of treatment for patients with recurrent subluxations. MRI can be used to confirm subluxation with a ligament tear

TreatmentReductionReduction

Cup affected elbow with Cup affected elbow with opposite hand opposite hand

Apply pressure over radial Apply pressure over radial head head

Thumb in antecubital Thumb in antecubital fossa fossa

Apply slight longitudinal Apply slight longitudinal traction by grasping wrist traction by grasping wrist

Supinate (palm up) and Supinate (palm up) and flex (to 90 degrees) flex (to 90 degrees) forearm forearm

Palpable click felt with Palpable click felt with reduction reduction

Post-reduction Post-reduction ManagementManagement

Child should be pain-free and use arm within Child should be pain-free and use arm within 0-15 minutes. Immobilization 0-15 minutes. Immobilization optionaloptional (Sling (Sling for 1-2 days) for 1-2 days)

If child fails to use arm after 15 minutes, If child fails to use arm after 15 minutes, obtain elbow views to rule out concomitant obtain elbow views to rule out concomitant fracturefracture

If x-rays normal but child still not using arm, If x-rays normal but child still not using arm, use a posterior splint and sling and re-use a posterior splint and sling and re-evaluate in 24 hoursevaluate in 24 hours

If child has 3 recurrent episodes of If child has 3 recurrent episodes of subluxation, then apply hard cast for 3 weekssubluxation, then apply hard cast for 3 weeks

Elbow X-rayElbow X-ray Views: Views:

APAP ObliqueOblique Lateral Lateral

Technique:Technique: Elbow in 90 degree Elbow in 90 degree

flexion flexion Compare with Compare with

opposite elbow opposite elbow

EvaluationEvaluation:: The radial head The radial head

should always point at should always point at the capitellum in all the capitellum in all views. A line drawn views. A line drawn down the long axis of down the long axis of the radius (radial the radius (radial head) should intersect head) should intersect the capitellum in all the capitellum in all views (if the line views (if the line doesn’t intersect, this doesn’t intersect, this is a sign of is a sign of dislocation)dislocation)

Differential Diagnosis If pain does not subside post-If pain does not subside post-

reduction, then suspect fracture reduction, then suspect fracture (x-rays required)(x-rays required)

Fracture, Elbow Fracture, Wrist Hand Injury, Soft Tissue Supracondylar Fracture /Salter-Supracondylar Fracture /Salter-

Harris FractureHarris Fracture Monteggia FractureMonteggia Fracture Green Stick FractureGreen Stick Fracture

Supracondylar FractureSupracondylar Fracture True supracondylar True supracondylar

fractures typically occur fractures typically occur just above the humeral just above the humeral epicondylesepicondyles

Salter-Harris fractures Salter-Harris fractures occur in the epiphysis of occur in the epiphysis of the humerus, are subtle the humerus, are subtle and often hard to and often hard to differentiate from differentiate from dislocations (line drawn dislocations (line drawn through the radius through the radius intersects with intersects with capitellum) capitellum)

Monteggia FractureMonteggia Fracture Fracture of the Fracture of the

proximal third of proximal third of ulna with radial ulna with radial head dislocationhead dislocation

Green Stick FractureGreen Stick Fracture Incomplete fracture Incomplete fracture

of the radius or of the radius or ulna which causes ulna which causes “bowing” of the “bowing” of the bonebone

Medication Once reduced, pain abates, and further therapy is unnecessary. Persistent pain is inconsistent with nursemaid elbow and should lead one to reconsider the diagnosis.Prevention Because nursemaid elbow tends to reoccur, families benefit from counseling. Avoidance of future axial traction should minimize risk of reoccurrence.

ReferencesReferences Choung, Walter, and Heinrich,Stephen. Choung, Walter, and Heinrich,Stephen.

Acute Annunlar Ligament Interposition Acute Annunlar Ligament Interposition into the Radiocapitellar Joint in Children into the Radiocapitellar Joint in Children (Nursemaid's Elbow). Journal of Pediatric (Nursemaid's Elbow). Journal of Pediatric Orthopedics. Vol. 15, No.4 1995Orthopedics. Vol. 15, No.4 1995

Waander, Hellerstein, and Ballock. Waander, Hellerstein, and Ballock. Nursemaid's Elbow, Pulling out the Nursemaid's Elbow, Pulling out the Diagnosis. Contemporary Pediatrics. June Diagnosis. Contemporary Pediatrics. June 20002000

Nursemaid’s Elbow, Nursemaid’s Elbow, Familypracticenotebook.comFamilypracticenotebook.com

Riego de Dios, Ricardo, and Norris, Burl. Riego de Dios, Ricardo, and Norris, Burl. Elbow Fractures and Dislocations. Elbow Fractures and Dislocations. eMedicine. July 2004eMedicine. July 2004