eMedicine Specialties > Clinical Procedures > Musculoskeletal Procedures

Joint Reduction, Radial Head Subluxation

Ryan P Lamb, MD, Attending Physician, Ultrasound Coordinator, Mills Peninsula Emergency Medical Associates

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 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, 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 tenderness or any obvious deformity is present.
Patients with known congenital lesions or neurologic deficits require a more detailed evaluation.

Anesthesia

Reduction of a subluxed radial head is generally a quick and easy procedure that requires no anesthesia. Acetaminophen or ibuprofen may be given to a child for pain relief.
In special situations, procedural sedation may be used; however, the risks usually outweigh the benefits in routine reductions.

Equipment

No equipment is necessary for this joint reduction.

Positioning

The patient stands or sits on the caregiver's lap for comfort and support during radial head reduction. The physician faces the patient and sits or kneels to be at the same eye level as the patient.

Technique

Two methods are popular for reducing a subluxed radial head: the supination technique and the hyperpronation technique.

With either technique, a palpable or audible click is associated with a high probability of successful reduction. Once the radial head is reduced, the child's pain and apprehension often immediately resolve. The practitioner should leave the patient's bedside immediately after the procedure and return to reevaluate in 10 minutes. The child usually begins to use the arm immediately, though some children may take up to 30 minutes to use the affected arm.⁵ If the first attempt is unsuccessful, a second attempt can be made; however, alternative diagnoses should be considered after 2 failed attempts.

The time from reduction to normal arm use is increased in younger patients and in those whose subluxations have been present for more than 12 hours. A 24-hour sling may be placed on the elbow for comfort; however, this is not necessary for most patients. Occasionally, symptoms may last for several days and a sling may be worn for longer. Recurrence of such an injury may be avoided by instructing parents and caregivers not to pull children by their arms.

Supination technique

This is the classic method of reduction.
Begin with the arm in pronation and the elbow in 90 degrees of flexion.
Place pressure over the patient's radial head.
For the supination technique, begin with the elbow flexed.
Hold the elbow in 90 degrees of flexion with pressure on the radial head.
Next, firmly supinate the wrist, keeping pressure on the radial head.
Supinate the wrist with the elbow still in 90 degrees of flexion.
While supinating, keep pressure on the radial head.
Then, flex the elbow completely. A click is often felt over the radial head when the arm has reached full supination.
Once supinated, fully flex the elbow.
With one hand supinating the wrist, the other thumb feels a click as the radial head falls into place on full flexion.
To perform the supination technique, begin with supination, then fully flex at the elbow.
Supination technique, side view.
Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-104158-109574.flv.
Supination technique, front view.
Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-104158-109599.flv.
This technique has an 80-92% success rate.

Hyperpronation technique

This method is emerging as the recommended technique of reduction.
Hold the patient's elbow in 90 degrees of flexion. Note that some practitioners prefer to have the elbow extended for this technique. Next, firmly hyperpronate the wrist.
Hyperpronation technique, front view.
Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-104158-109601.flv.
For the reduction of subluxation of the radial head, the hyperpronation technique results in fewer failures than supination.⁶ Pronation has also been suggested to be less painful; therefore, the hyperpronation technique has been advocated as the first-line reduction maneuver.^7,8
By combining both techniques (hyperpronation followed by supination), reduction can occur, and the assessment for proper return of function and movement occurs as well.

Pearls

Some practitioners advocate teaching the parents or caregivers how to reduce a subluxed radial head in case of recurrences.
As with any injury, document the neurologic and vascular status before and after manipulation.

Complications

If the above reduction techniques do not result in normal function within 30 minutes, consider an alternative diagnosis.
About 2-4 reduction attempts may be made 15 minutes apart. If the child does not begin using the arm normally after such attempts, a radiograph should be obtained to look for fractures or other complications.
If one technique fails initially, the other may be attempted.
If multiple reduction attempts prove unsuccessful, a sling or posterior long arm splint may be applied for comfort, and the child can be referred to an orthopedist.
As many as 27% of patients experience recurrence, which may be treated with immobilization.
Ultrasonography can be used to follow recurrent subluxations to be sure that reduction has occurred and that the annular ligament has healed after brace treatment.⁹
Rare complications include fractures that result from reduction or required operative repair of the subluxation.

Special Concerns

Upon presentation of any injured child, the physician must consider possible abuse, especially in cases of recurrent subluxation.

Multimedia

Media file 1: Subluxation occurs after longitudinal traction is placed on a pronated extended arm.

Media file 2: The subluxed arm is held semiflexed, adducted, and pronated.

Media file 3: Alternative diagnoses should be sought if point tenderness or any obvious deformity is present.

Media file 4: For the supination technique, begin with the elbow flexed.

Media file 5: Hold the elbow in 90 degrees of flexion with pressure on the radial head.

Media file 6: Supinate the wrist with the elbow still in 90 degrees of flexion.

Media file 7: While supinating, keep pressure on the radial head.

Media file 8: Once supinated, fully flex the elbow.

Media file 9: With one hand supinating the wrist, the other thumb feels a click as the radial head falls into place on full flexion.

Media file 10: To perform the supination technique, begin with supination, then fully flex at the elbow.

Media file 11: Hyperpronate the arm.

Media file 12: With one hand distally, hyperpronate the arm while the other hand holds the elbow steady with the thumb on the radial head.

Media file 13: Shortly after reduction, the child resumes using the affected arm.

Media file 14: Supination technique, side view.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-104158-109574.flv.

Media file 15: Supination technique, front view.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-104158-109599.flv.

Media file 16: Hyperpronation technique, side view.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-104158-109600.flv.

Media file 17: Hyperpronation technique, front view.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-104158-109601.flv.

References

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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

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.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Gretchen S Lent, MD, to the development and writing of this article.

Further Reading