Topic

• Introduction
• Indications
• Contraindications
• Procedure
• Coding Information

Figure(s)

• Technique to Accomplish Reduction

• Subluxation of the radial head ("nursemaid's elbow") is a common childhood injury that is seen most often in patients between 6 months and 5 yrs of age.
• The radial head normally rotates against the ulna and capitellum (i.e., humerus), permitting forearm pronation and supination. The radial head is held in place against the proximal ulna and capitellum by ligaments and the joint capsule. Radial head subluxation usually is caused by the application of linear traction to a hand or wrist (i.e., longitudinal traction injury)—e.g., by lifting a child by an outstretched hand. It may also be caused by an incidental fall in which the arm, elbow, and forearm are impacted between the ground and the child's trunk. Rarely, there is no known history of trauma, but parents notice that the child is not using the affected limb.
• Approach a child with suspected subluxation slowly and calmly to allay anxiety. The affected arm is partially flexed at the elbow and in forearm pronation. Typically, the child keeps the arm close to the trunk and appears contented and playful but declines to actively move the affected arm.
• There is no tenderness to palpation of the clavicle, shoulder, humerus, elbow, forearm, wrist, or hand, and passive range of motion of the shoulder, hand, and wrist is usually painless. However, even modest attempts to supinate the forearm or to move the elbow elicit pain and anguish. Radiographs are usually unnecessary, and physical exam effectively diagnoses the problem.
• After a reduction attempt, the child usually cries for a few seconds but then is easily comforted. Observe for 15 mins for a full return to normal use. If function and use have not normalized within 15 mins, a repeated attempt at reduction is recommended. Consider alternative diagnoses if the child's arm does not return to normal.
• Gently remind parents to avoid lifting the child by the hand, wrist, or forearm. Inform parents that there is an increased risk of recurrence until the child reaches 5–6 yrs of age. Recurrent subluxation occurs in nearly one-fourth of patients, and those aged 24 months are at greatest risk.

Reduction of a subluxed radial head.

Uncertainty about the diagnosis or possibility of occult fracture (i.e., further workup indicated)

Place child's elbow in the fingers of your hand and your thumb over child's radial head (i.e., lateral aspect of proximal forearm). Grasp child's affected hand with your other hand. Rapidly apply downward pressure on the radial head with your thumb, quickly followed by full supination and then full flexion of child's elbow (Fig. 62-1). A "click'' is often palpated by the physician's thumb as reduction is accomplished.

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