eMedicine Specialties > Clinical Procedures > Musculoskeletal Procedures

Joint Reduction, Radial Head Subluxation

Author: Ryan P Lamb, MD, Attending Physician, Ultrasound Coordinator, Mills Peninsula Emergency Medical Associates
Contributor Information and Disclosures

Updated: Nov 19, 2009

Introduction

Radial head subluxation, also known as nursemaid's elbow, is the most common upper extremity injury in infants and young children who present to the emergency department (ED). Reduction of the radial head is easily performed in the ED with few complications.

Subluxation of the radial head is a minor injury with a peak incidence in children aged 2-3 years. Radial head subluxation does occur in patients younger than 6 months as well as in older children. This injury typically results from a quick pull on a child's arm.1 Often this occurs as the child is holding hands with a caregiver who lifts the child by the hand or tries to prevent a fall. Therefore, the parents may provide a history of a fall or may be unsure what caused the injury, as the mechanical force can be trivial.2

Subluxation occurs after longitudinal traction is...

Subluxation occurs after longitudinal traction is placed on a pronated extended arm.

[ CLOSE WINDOW ]
Subluxation occurs after longitudinal traction is...

Subluxation occurs after longitudinal traction is placed on a pronated extended arm.


The annular ligament is generally weak in young children. Thus, when longitudinal traction is placed on an extended pronated arm, the radial head may slip into the radiocapitellar articulation, resulting in subluxation. The left arm is more commonly involved, presumably because most caretakers are right-handed. Girls are affected more often than boys.

Upon presentation, the parents often note that the child is not using or bending the affected arm. Many times, the parents believe the wrist has been injured, as the child is often holding on to his or her hand or wrist. The child with a radial head subluxation presents in no distress, with the affected arm semiflexed, adducted, and pronated.3

The subluxed arm is held semiflexed, adducted, an...

The subluxed arm is held semiflexed, adducted, and pronated.

[ CLOSE WINDOW ]
The subluxed arm is held semiflexed, adducted, an...

The subluxed arm is held semiflexed, adducted, and pronated.


Radiograph findings are often normal, when performed. However, radiographs are usually not typically necessary provided there is no history of significant trauma and there is no deformity or focal tenderness (apart from at the radial head) noted on examination.4 The positioning required to take proper radiographs often reduces the radial head into place. The lateral elbow may have mild tenderness, and attempts to pronate or supinate the arm cause pain. All other range of motion is often permitted. No significant edema or effusion should be found on clinical examination.

Indications

The diagnosis is mostly supported by a child holding the elbow slightly flexed and pronated and a lack of ecchymosis, significant tenderness, or edema to the affected joint.

Contraindications

  • A diagnosis other than radial head subluxation should be sought if the history includes trauma to the arm, swelling, significant tenderness, deformity, or ecchymosis to the patient's elbow.

  • Alternative diagnoses should be sought if point t...

    Alternative diagnoses should be sought if point tenderness or any obvious deformity is present.

    [ CLOSE WINDOW ]
    Alternative diagnoses should be sought if point t...

    Alternative diagnoses should be sought if point tenderness or any obvious deformity is present.

  • Patients with known congenital lesions or neurologic deficits require a more detailed evaluation.

More on Joint Reduction, Radial Head Subluxation

Overview: Joint Reduction, Radial Head Subluxation
Treatment & Medication: Joint Reduction, Radial Head Subluxation
Multimedia: Joint Reduction, Radial Head Subluxation
References
[ CLOSE WINDOW ]

References

  1. Bretland PM. Pulled elbow in childhood. Br J Radiol. Dec 1994;67(804):1176-85. [Medline].

  2. Schunk JE. Radial head subluxations: Epidemiology and treatment of 87 episodes. Ann Emerg Med. 1990;19:1019-1023. [Medline].

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

  4. Choung W, Heinrich SD. Acute annular ligament interposition into the radiocapitellar joint in children (nursemaid's elbow). J Pediatr Orthop. Jul-Aug 1995;15(4):454-6. [Medline].

  5. Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child. Dec 1985;139(12):1194-7. [Medline].

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

  7. Krul M, van de Wouden JC, van Suijlekom-Smit LWA. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systemic Reviews [serial online]. Oct 2009;4:Accessed April 19, 2009. Available at http://www.cochrane.org/reviews/en/ab007759.html.

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

  9. Kim MC, Eckhardt BP, Craig C, Kuhns LR. Ultrasonography of the annular ligament partial tear and recurrent "pulled elbow". Pediatr Radiol. Dec 2004;34(12):999-1004. [Medline].

  10. Hay W. Current Pediatrics. 17th ed. New York, NY: McGraw-Hill; 2005.

  11. Hutchinson J. Partial dislocation of the head of the radius peculiar to children. Br Med J. 1886;1:9-10.

  12. Illingworth CM. Pulled elbow: a study of 100 patients. Br Med J. Jun 21 1975;2(5972):672-4. [Medline].

  13. Lewis D, Argall J. Reduction of pulled elbows. Emerg Med J. Jan 2003;20(1):61-2. [Medline].

  14. Lyver MB. Radial head subluxation. J Emerg Med. May-Jun 1991;9(3):154-6. [Medline].

  15. Macias CG, Wiebe R, Bothner J. History and radiographic findings associated with clinically suspected radial head subluxations. Pediatr Emerg Care. Feb 2000;16(1):22-5. [Medline].

  16. Nichols J. Nursemaid's elbow: reducing it to simple terms. Contemp Pediatr. 1988;5:50-55.

  17. Salter RB, Zaltz C. Anatomic investigations of the mechanism of injury and pathologic anatomy of "pulled elbow" in young children. Clin Orthop Relat Res. 1971;77:134-43. [Medline].

  18. Schutzman SA, Teach S. Upper-extremity impairment in young children. Ann Emerg Med. Oct 1995;26(4):474-9. [Medline].

  19. Snellman O. Subluxation of the head of the radius in children. Acta Orthop Scand. 1959;28:311-5. [Medline].

  20. Tintinalli, Kelen, Stapczynski. Emergency Medicine: A comprehensive Study guide. 6th ed. New York, NY: McGraw-Hill; 2004.

  21. Way L, Doherty G. Current Surgical Diagnosis and Treatment. 11th ed. New York, NY: McGraw-Hill; 2003.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

radial head subluxation, elbow dislocation, elbow injury, nursemaid's elbow, subluxation of the radial head, pulled elbow, upper extremity injury, young children, joint reduction, elbow injury

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Ryan P Lamb, MD, Attending Physician, Ultrasound Coordinator, Mills Peninsula Emergency Medical Associates
Ryan P Lamb, MD is a member of the following medical societies: American College of Emergency Physicians and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.