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Radial Head Radial Head Subluxation and Subluxation and Associated Associated Complications Complications Aimee Disharoon Aimee Disharoon December 14, 2005 December 14, 2005

Radial Head Subluxation

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Page 1: Radial Head Subluxation

Radial Head Radial Head Subluxation and Subluxation and

Associated Associated ComplicationsComplications

Aimee DisharoonAimee Disharoon

December 14, 2005December 14, 2005

Page 2: Radial Head Subluxation

Radial Head SubluxationRadial Head Subluxation AKA “Nursemaids’ Elbow”AKA “Nursemaids’ Elbow” Common injury that is seen most often in Common injury that is seen most often in

children between the ages of 1-6 yearschildren between the ages of 1-6 years 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 their when small children are swung by their arms.arms.

Page 3: Radial Head Subluxation

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

Page 4: Radial Head Subluxation

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

and held by side, child will not useand held by side, child will not use 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 and their arms arm after rolling over and their arms getting caught getting caught

Page 5: Radial Head Subluxation

RadiographsRadiographs

Diagnosis is by history and physical Diagnosis is by history and physical examination. Radiograph examination is examination. Radiograph examination is usually not necessary and are normal in usually not necessary and are normal in most instances. most instances.

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

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

Page 6: Radial Head Subluxation

ReductionReduction 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 fossa Thumb in antecubital 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

Page 7: Radial Head Subluxation

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 optional (Sling 0-15 minutes. Immobilization optional (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

Page 8: Radial Head Subluxation

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 should The radial head should

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

Page 9: Radial Head Subluxation

ComplicationsComplications If pain does not subside If pain does not subside

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

Supracondylar Fracture Supracondylar Fracture /Salter-Harris Fracture/Salter-Harris Fracture

Monteggia FractureMonteggia Fracture Green Stick FractureGreen Stick Fracture

Fractures can be seen as lines tranversing the bone, displace-ment of one end of bone relative to the other end, and as joint effusions or “fat pads”

Page 10: Radial Head Subluxation

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)

Page 11: Radial Head Subluxation

Monteggia FractureMonteggia Fracture

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

Page 12: Radial Head Subluxation

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

Page 13: Radial Head Subluxation

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

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

Waander, Hellerstein, and Ballock. Nursemaid's Waander, Hellerstein, and Ballock. Nursemaid's Elbow, Pulling out the Diagnosis. Contemporary Elbow, Pulling out the Diagnosis. Contemporary Pediatrics. June 2000Pediatrics. June 2000

Nursemaid’s Elbow, Familypracticenotebook.comNursemaid’s Elbow, Familypracticenotebook.com Riego de Dios, Ricardo, and Norris, Burl. Elbow Riego de Dios, Ricardo, and Norris, Burl. Elbow

Fractures and Dislocations. eMedicine. July 2004Fractures and Dislocations. eMedicine. July 2004