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Radial Head Radial Head Subluxation and Subluxation and
Associated Associated ComplicationsComplications
Aimee DisharoonAimee Disharoon
December 14, 2005December 14, 2005
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.
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 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
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.
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
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
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)
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”
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
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