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Basics ⬇

Author(s): JohnMunyak, MD, YaffaIlyaguyeva and AmityTung, MD

Description

  • Results from a traumatic subluxation of the radial head, which is produced by sudden forcible traction on the pronated hand or wrist with the relaxed elbow extended
  • Subluxation of the radial head only occurs in pronation when the anteroposterior (AP) plane of the radial head diameter is narrowest.
  • As the radial head subluxes, there is an interposition of the annular ligament in the radiocapitellar joint resulting in entrapment.
  • Synonym(s): pulled elbow; radiocapitellar subluxation; subluxation of the head of the radius; subluxation of the radius by elongation; temper tantrum elbow; Malgaigne injury

Epidemiology

  • One of the most common musculoskeletal injuries in children age 4 yr and under
  • Uncommon in children >5 yr of age because the distal attachments of the orbicular ligament are sufficiently strong to prevent occurrence
  • Peak incidence is from age of 1 to 3 yr old (1), with a predominance in females (2).

Risk-Factors

  • Frequently, the traction force occurs when the child suddenly attempts to pull away from a parent or drops to the ground.
  • Pulling a child as he or she stumbles, lifting him or her up by the hand, or swinging the child by the hand(s) can also generate sufficient traction force.

Diagnosis ⬆ ⬇

  • History alone is the basis for diagnosis in most cases.
  • Consider prereduction radiographs if there is a history of trauma.
  • Postreduction views are unnecessary.
  • Consider x-rays if the child’s arm does not return to normal function after performing appropriate reduction maneuvers.
  • Consider additional imaging of the forearm, wrist, or humerus in young children.

History

  • In >80% of cases, there is a history of sudden longitudinal traction to a pronated, extended forearm (3).
  • May be a history of a “click” felt or heard by the person who pulled the child’s arm
  • May be a history of an incidental fall in which the arm, elbow, and forearm were impacted between the ground and the child’s trunk (3)
  • Immediately following the injury, the child is usually tearful due to the pain and refuses to use the affected arm.
  • Pain, if vocalized, may be referred toward the wrist.
  • The child holds the forearm by his or her side, always in a pronated and partially flexed position (nursemaid’s position).
  • Often, there is no history of trauma and the parents may notice the affected extremity not being used.

Physical Exam

  • Child refuses to use the affected limb.
  • The forearm is always pronated, and the elbow is partially flexed.
  • The child typically holds the affected limb by his or her side, sometimes supporting the forearm with the other hand.
  • The child may be tearful during physical exam.
  • The child also may appear content and playful but declines to move the affected arm.
  • Gentle palpation can reveal local tenderness over the anterolateral aspect of the radial head.
  • By carefully avoiding movements involving the elbow and forearm, one can note painless range of motion of the wrist, hand, and shoulder.
  • Typically, no obvious swelling or deformity
  • There is minimal restriction to flexion and extension of the elbow, but supination of the forearm is markedly limited and resisted.
  • Often, the appearance is that of a wrist injury with the wrist flexed and pronated.
  • It is imperative to examine the joints above and below the suspected injury, as well as the clavicle, to increase the likelihood of identifying the primary injury site.

Differential Diagnosis

  • Posterior elbow dislocation
  • Distal radial buckle fracture (torus) or other radial fracture
  • Ulnar fracture
  • Supracondylar fracture or other fracture of the humerus
  • Avulsion of the medial or lateral epicondyle
  • Septic joint
  • Synovitis

Treatment ⬆ ⬇

General Measures

  • Analgesia:
    • Not typically necessary for reduction
    • Consider acetaminophen (15 mg/kg) or ibuprofen (5 to 10 mg/kg) as needed.
  • Reduction techniques: flexion–supination and hyperpronation (4)
  • Flexion–supination:
    • The thumb is placed in the region of the radial head for palpation and the exertion of mild pressure (anterior to posterior).
    • The child’s forearm is gently but firmly rotated into full supination.
    • The elbow is then flexed to 90 degrees by holding the child’s forearm above the wrist and stabilizing the humerus and elbow with the other hand to prevent rotation of the shoulder. If any resistance is met, one should continue flexing the elbow to the point of maximal flexion.
    • As reduction is achieved, a palpable and sometimes audible “click” can be felt in the region of the radial head.
    • This maneuver will typically achieve instantaneous reduction of the radial head and instant relief of pain.
  • Hyperpronation:
    • Additional pressure is exerted to pronate the forearm further as the elbow is moved into full extension; if done correctly, may be more effective and less painful (5)
  • Postreduction evaluation:
    • Observation is necessary until there is a return of full function and use of the affected arm (often occurs immediately postmaneuver).
    • If function has not normalized in 15 min, a repeated attempt at reduction is recommended or obtain radiographs.
    • In some studies, the delay until normal use of the arm is achieved is longer when there has been a delay in treatment from the time of injury; therefore, near normal function or significant improvement in function and postreduction may be sufficiently reassuring to continue observation at home with close follow-up within 24 hr.
    • If there is no evidence of recovery after several reduction attempts, the diagnosis must be reconsidered.
  • Immobilization:
    • Immobilization is not necessary for the first occurrence of subluxation.
    • If reduction is delayed for >12 hr, consider immobilization in a sling and swathe or with a posterior mold for 10 days with the elbow in 90 degrees of flexion and the forearm in full supination. Compliance is difficult in this age range.
    • For cases of multiple recurrences of nursemaid’s elbow, some clinicians recommend a trial of immobilization of the upper limb in an above elbow cast or postmold for 2 to 3 wk in conjunction with pediatric orthopedic consultation.

Additional Therapies

  • Special considerations:
    • In a child <6 mo of age, consider abuse from a caretaker while evaluating the child. However, subluxation can occur while simply rolling over in this age group.
    • Recurrence of subluxation as a result of subsequent pulls occurs in ~5–40% of cases.
  • Rehabilitation:
    • Prevention is key. The parent should be advised to avoid longitudinal traction strains on the arm by not pulling on the hand or wrist, but pick the child up by the trunk.
    • For the child who recovers fully after one or two reduction maneuvers, further therapy or intervention is unnecessary.

Surgery/Other Procedures

  • Very rarely, the subluxed radial head may be irreducible by manipulation, especially in recurrent cases, requiring surgical intervention.
  • The need for open reduction is extremely rare.

Ongoing Care ⬆ ⬇

Follow-up Recommendations

  • Even when multiple attempts at closed reduction fail, spontaneous reduction almost always occurs.
  • Usually no long-term sequelae
  • Consider an occult fracture or cartilaginous injury if the response to treatment is not typical.

Additional Reading ⬆ ⬇

Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med. 1990;19(9):1019–1023.

References ⬆ ⬇

  1. Vitello S, Dvorkin R, Sattler S, et al. Epidemiology of nursemaid’s elbow. West J Emerg Med. 2014;15(4):554–557.
  2. Wong K, Troncoso AB, Calello DP, et al. Radial head subluxation: factors associated with its recurrence and radiographic evaluation in a tertiary pediatric emergency department. J Emerg Med. 2016;51(6):621–627.
  3. Welch R, Chounthirath T, Smith GA. Radial head subluxation among young children in the United States associated with consumer products and recreational activities. Clin Pediatr (Phila). 2017;56(8):707–715.
  4. Krul M, van der Wouden JC, Kruithof EJ, et al. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2017;(7):CD007759.
  5. Bexkens R, Washburn FJ, Eygendaal D, et al. Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: a systematic review and meta-analysis. Am J Emerg Med. 2017;35(1):159–163.

Clinical Pearls ⬆

  • Commonly occurring traction injury age <4 yr
  • Educating families to avoid pulling or putting traction on the child’s arm for several days following injury significantly decreases the risk of recurrence.
  • Long-term sequelae unlikely
  • Evaluate returned usage of the elbow by making the child reach for a favorite object, parent’s hand, or “eye candy.”
  • Consider fracture in the setting of antecedent trauma, significant swelling, deformity, or in cases of failed reduction attempts.