Patient Education and Consent
Recurrence of radial head subluxation may be avoided by instructing parents and caregivers not to pull children by their arms. Some practitioners advocate teaching parents or caregivers how to reduce a subluxated radial head so that they can provide appropriate management in the event of a recurrence. Cases in which the subluxation was diagnosed and treated over the telephone have been reported. [10]
Preprocedural Evaluation
Children are often brought for evaluation because they are not using the affected arm. Because these children often support the affected hand or wrist, caregivers may suspect wrist injury. An examination quickly rules out injury to these areas.
A child with a radial head subluxation usually is not in any distress. The affected arm is held semiflexed, adducted, and pronated (see the image below). [11] The lateral elbow may be mildly tender, and attempts to pronate or supinate the arm may cause pain. All other range of motion is often permitted.
In radial head subluxation, subluxated arm is held semiflexed, adducted, and pronated.
No significant edema or effusion should be found on clinical examination. If focal swelling or other areas of tenderness are present, radiographs should be performed. The examiner should keep in mind that fractures, especially supracondylar ones, can be mistaken for simple subluxations. [12]
As a rule, if there is no history of significant trauma and if no deformity or local tenderness (other than that at the radial head) is noted, radiographs are not necessary. [13] When radiography is performed, the radiographs of the subluxated radial head are typically normal; however, they can sometimes demonstrate subtle discontinuity of the radius and capitellum along a straight line. [14] The positioning required to take proper radiographs often reduces the radial head into place.
Ultrasonography can also be used to demonstrate displacement of the cartilaginous radial head away from the capitellum. [15] Arthrography is useful for detecting occult subluxations in children with other operative injuries of the elbow. [16]
As with any injury, neurologic and vascular status should be documented both before and after manipulation.
Patient Preparation
Anesthesia
Reduction of a radial head subluxation 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, in routine reductions, the risks of sedation usually outweigh the benefits.
Positioning
During radial head reduction, the patient stands or sits on the caregiver’s lap for comfort and support. The physician faces the patient and sits or kneels to be at the same eye level.
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Subluxation of radial head occurs after longitudinal traction is placed on pronated extended arm.
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In radial head subluxation, subluxated arm is held semiflexed, adducted, and pronated.
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Alternative diagnoses to radial head subluxation should be sought if point tenderness or any obvious deformity is present.
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Reduction of subluxated radial head: supination-flexion. Technique begins with elbow flexed.
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Reduction of subluxated radial head. Shortly after reduction, child resumes using affected arm.
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Reduction of subluxated radial head: supination-flexion. Wrist is supinated with elbow still in 90° of flexion.
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Reduction of subluxated radial head: supination-flexion. During supination, pressure is maintained on radial head.
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Reduction of subluxated radial head: supination-flexion. After supination, elbow is fully flexed.
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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.
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Reduction of subluxated radial head: supination-flexion. Technique begins with supination, followed by full flexion at elbow.
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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.
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Shortly after reduction, child resumes using affected arm.
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Reduction of subluxated radial head: supination-flexion. Side view of technique.
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Reduction of subluxated radial head: supination-flexion. Front view of technique.
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Reduction of subluxated radial head: hyperpronation/forced pronation. Side view of technique.
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Reduction of subluxated radial head: hyperpronation/forced pronation. Front view of technique.
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Elbow anatomy with annular ligament.
