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Reduction of Radial Head Subluxation Technique

  • Author: Gretchen S Lent, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: May 16, 2016
 

Approach Considerations

Radial head subluxation is managed by means of manual reduction. Either of the following two reduction methods may be used:

  • Supination-flexion technique
  • Hyperpronation/forced pronation technique

If one technique fails initially, the other may be attempted.

A 2012 Cochrane review evaluated the literature available for comparison of the two techniques.[17] The reviewers found only four trials, with a total of 379 participants; overall, the methodologic quality was low. Limited evidence from these trials suggested that the hyperpronation method was more effective and less painful.

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Supination-Flexion Technique

The supination-flexion technique (see the image below) is the classic method of reducing a subluxated radial head. It has a success rate of 80-92%.

Reduction of subluxated radial head: supination-fl Reduction of subluxated radial head: supination-flexion. Technique begins with supination, followed by full flexion at elbow.

The procedure begins with the patient’s arm in pronation and elbow in 90° of flexion, with pressure applied over the patient’s radial head (see the images below).

Reduction of subluxated radial head: supination-fl Reduction of subluxated radial head: supination-flexion. Technique begins with elbow flexed.
Reduction of subluxated radial head. Shortly after Reduction of subluxated radial head. Shortly after reduction, child resumes using affected arm.

Next, the wrist is firmly supinated, with pressure maintained on the radial head (see the images below).

Reduction of subluxated radial head: supination-fl Reduction of subluxated radial head: supination-flexion. Wrist is supinated with elbow still in 90° of flexion.
Reduction of subluxated radial head: supination-fl Reduction of subluxated radial head: supination-flexion. During supination, pressure is maintained on radial head.

The patient’s elbow is then completely flexed (see the images and videos below). A click is often felt over the radial head (or heard) when the arm has reached full flexion. A palpable or audible click is associated with a high probability of successful reduction.

Reduction of subluxated radial head: supination-fl Reduction of subluxated radial head: supination-flexion. After supination, elbow is fully flexed.
Reduction of subluxated radial head: supination-fl Reduction of subluxated radial head: supination-flexion. With one hand supinating wrist, other thumb feels click as radial head falls into place on full flexion.
Reduction of subluxated radial head: supination-flexion. Side view of technique.
Reduction of subluxated radial head: supination-flexion. Front view of technique.
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Hyperpronation/Forced Pronation Technique

Although the hyperpronation technique (also known as the forced pronation technique) was first described in 1886 by Hutchinson, it has only comparatively recently begun to emerge as a potentially superior means of reduction.

First, the patient’s elbow is held in 90° of flexion. (Some practitioners prefer to have the elbow extended for this technique.) Next, the wrist is firmly hyperpronated (see the image and videos below). As with the supination-flexion technique, a palpable or audible click is associated with a high probability of successful reduction.

Reduction of subluxated radial head: hyperpronatio Reduction of subluxated radial head: hyperpronation/forced pronation. With one hand placed distally, arm is hyperpronated while other hand holds elbow steady with thumb on radial head.
Reduction of subluxated radial head: hyperpronation/forced pronation. Side view of technique.
Reduction of subluxated radial head: hyperpronation/forced pronation. Front view of technique.

In a few studies, the hyperpronation technique resulted in fewer failures than supination.[1] It has been suggested that hyperpronation may also be less painful; accordingly, some have advocated hyperpronation as the first-line reduction maneuver.[17, 18, 19]

Using a combination of the two techniques (hyperpronation followed by supination) to ensure reduction has been proposed. Such a combined approach would allow simultaneous assessment the return of proper range of motion.

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Postprocedural Care

Once the radial head has been 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. Most children begin to use the affected arm immediately, though some may take as long as 30 minutes to start doing so (see the image below).[20] The time from reduction to normal arm use is increased in younger patients and those whose subluxations have been present for more than 12 hours.

Shortly after reduction, child resumes using affec Shortly after reduction, child resumes using affected arm.

If the first attempt at reduction proves unsuccessful, further attempts can be made (~15 minutes apart); however, alternative diagnoses should be considered after multiple failed attempts. 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.[21] When 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.

Although a 24-hour sling may be placed on the elbow for comfort, this measure is not necessary for most patients. Occasionally, symptoms may last for several days, and a sling may be worn for longer.

Ultrasonography can be used to evaluate subluxations and determine the success of reduction. Furthermore, it can be used to confirm the healing of the annular ligament after treatment in complex cases.[22]

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Contributor Information and Disclosures
Author

Gretchen S Lent, MD Attending Physician, Department of Emergency Medicine, Torrance Memorial Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

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, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgements

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.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; 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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
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  2. Pearson BV, Kuhns DW. Nursemaid's elbow in a 31-year old female. American Journal of Emergency Medicine. February 2007. 25:222-223. [Medline].

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

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

  5. Kim JH, Lee HJ, Baek GH. Intra-articular osteoid osteoma in the proximal ulna combined with radial head subluxation: a case report. J Shoulder Elbow Surg. 2012 Aug. 21(8):e1-5. [Medline].

  6. Curtis E. Managing 'pulled elbow' in the paediatric emergency department. Emerg Nurse. 2012 Feb. 19(9):24-7; quiz 29. [Medline].

  7. Meiner EM, Sama AE, Lee DC, Nelson M, Kats DS, Trope A. Bilateral nursemaid's elbow. American Journal of Emergency Medicine. October 2004. 22:502-503. [Medline].

  8. Van Zeeland NL, Bae DS, Goldfarb CA. Intra-articular radial head fracture in the skeletally immature patient: progressive radial head subluxation and rapid radiocapitellar degeneration. J Pediatr Orthop. 2011 Mar. 31(2):124-9. [Medline].

  9. Tatebe M, Hirata H, Shinohara T, Yamamoto M, Morita A, Horii E. Pathomechanical significance of radial head subluxation in the onset of osteochondritis dissecans of the radial head. J Orthop Trauma. 2012 Jan. 26(1):e4-6. [Medline].

  10. Kaplan RE, Lillis KA. Recurrent nursemaid's elbow (annular ligament displacement) treatment via telephone. Pediatrics. July 2008. 110:171-174. [Medline].

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

  12. Kraus R, Dongowski N, Szalay G, Schnettler R. Missed elbow fractures misdiagnosed as radial head subluxations. Acta Orthopaedica Belgica. June 2010. 76:312-315. [Medline].

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

  14. Frumkin K. Nursemaid's elbow: A radiographic demonstration. Annals of Emergency Medicine. 1985. 14:690-693.

  15. Shabat S, Folman F, Mann G, Kots Y, Fredman B, Banian M, et al. The role of sonography in detecting radial head subluxation in a child. Journal of Clinical Ultrasound. May 2005. 33:187-189. [Medline].

  16. Lee DH, Han SB, Park JH, Park SY, Jeong WK, Lee SH. Elbow arthrography in children with an ulnar fracture and occult subluxation of the radial head. J Pediatr Orthop B. 2011 Jul. 20(4):257-63. [Medline].

  17. Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2012 Jan 18. 1:CD007759. [Medline].

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

  19. Green DA, Linares MYR, Garcia P, Greenberg B, Bakery RL. Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. Pediatric Emergency Care. April 2006. 22:235-238. [Medline].

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

  21. Joffe MD, Loiselle J. Orthopedic emergencies. Ludwig S, Henretig FM. Textbook of Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams and Wilkins; 2000. 1601.

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

 
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Subluxation of radial head occurs after longitudinal traction is placed on pronated extended arm.
In radial head subluxation, subluxated arm is held semiflexed, adducted, and pronated.
Alternative diagnoses to radial head subluxation should be sought if point tenderness or any obvious deformity is present.
Reduction of subluxated radial head: supination-flexion. Technique begins with elbow flexed.
Reduction of subluxated radial head. Shortly after reduction, child resumes using affected arm.
Reduction of subluxated radial head: supination-flexion. Wrist is supinated with elbow still in 90° of flexion.
Reduction of subluxated radial head: supination-flexion. During supination, pressure is maintained on radial head.
Reduction of subluxated radial head: supination-flexion. After supination, elbow is fully flexed.
Reduction of subluxated radial head: supination-flexion. With one hand supinating wrist, other thumb feels click as radial head falls into place on full flexion.
Reduction of subluxated radial head: supination-flexion. Technique begins with supination, followed by full flexion at elbow.
Reduction of subluxated radial head: hyperpronation/forced pronation. With one hand placed distally, arm is hyperpronated while other hand holds elbow steady with thumb on radial head.
Shortly after reduction, child resumes using affected arm.
Reduction of subluxated radial head: supination-flexion. Side view of technique.
Reduction of subluxated radial head: supination-flexion. Front view of technique.
Reduction of subluxated radial head: hyperpronation/forced pronation. Side view of technique.
Reduction of subluxated radial head: hyperpronation/forced pronation. Front view of technique.
Elbow anatomy with annular ligament.
 
 
 
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