In adults, the radial head is wider than the radial neck; consequently, the head cannot fit through the ligaments that tightly surround the neck. However, in toddlers (about 2 to 3 years old), the radial head is no wider than the radial neck and can easily slip through these ligaments (radial head subluxation).
Subluxation results from traction on the forearm, as when a caregiver pulls a reluctant toddler forward or catches the toddler by the wrist during a fall—actions many caregivers do not remember.
(See Overview of Dislocations Overview of Dislocations A dislocation is complete separation of the 2 bones that form a joint. Subluxation is partial separation. Often, a dislocated joint remains dislocated until reduced (realigned) by a clinician... read more .)
Symptoms and Signs of Radial Head Subluxations
Symptoms of radial head subluxation may include pain and tenderness. Most patients cannot describe their symptoms and simply present with unwillingness to move the affected arm. The radial head may be only mildly tender.
Diagnosis of Radial Head Subluxations
Usually history
Plain x-rays are normal and considered unnecessary by some experts when patients have a clear history of a traction injury, unless an alternate diagnosis is clinically suspected (1 Diagnosis reference Radial head subluxation, common among toddlers, is caused by traction on the forearm and usually manifests as refusal to move the elbow (pseudoparalysis). In adults, the radial head is wider... read more ).
Using a reduction maneuver may be diagnostic and therapeutic.
Diagnosis reference
1. Eismann EA, Cosco ED, Wall EJ: Absence of radiographic abnormalities in nursemaid's elbows. J Pediatr Orthop 34 (4):426–431, 2014. doi: 10.1097/BPO.0000000000000126
Treatment of Radial Head Subluxations
Reduction
Reduction may be done using
Supination-flexion
Hyperpronation
Neither technique requires sedation or analgesia; the child experiences pain only for a few seconds. Hyperpronation has a higher first-attempt success rate (1 Treatment reference Radial head subluxation, common among toddlers, is caused by traction on the forearm and usually manifests as refusal to move the elbow (pseudoparalysis). In adults, the radial head is wider... read more ). (See also How To Reduce a Radial Head Subluxation How To Reduce a Radial Head Subluxation (Nursemaid Elbow) A hyperpronation or a supination-flexion technique may be used to reduce a radial head subluxation (nursemaid elbow). These techniques are safe and require no special equipment, assistants,... read more .)
In supination-flexion, the elbow is completely extended and supinated, then flexed. A subtle palpable pop or click is often detected when the radial head resumes its normal position.
In hyperpronation, the practitioner supports the child's arm at the elbow and places moderate pressure with a finger on the radial head. The practitioner then grips the distal forearm with the other hand and hyperpronates the forearm. A pop can be felt at the radial head when it is reduced.
Children usually start to move the elbow after about 10 to 20 minutes. If they do not move it, x-rays of the elbow should be taken. If they do move it, x-rays and immobilization are unnecessary.
If pain or dysfunction lasts > 24 hours, incomplete reduction or an occult fracture should be suspected. Radial head subluxation recurs in 20 to 40% of children.
Treatment reference
1. Bek D, Yildiz C, Köse O, et al: Pronation versus supination maneuvers for the reduction of 'pulled elbow': A randomized clinical trial. Eur J Emerg Med 16 (3):135–138, 2009. doi: 10.1097/MEJ.0b013e32831d796a
Key Points
Radial head subluxation, common among toddlers, can occur when a caregiver pulls a reluctant toddler forward or catches the toddler by the wrist during a fall—actions many caregivers do not remember.
Most patients cannot describe their symptoms; the only indication of the injury may be unwillingness to move the affected arm.
Diagnose based on history unless an alternate diagnosis is suspected.
Treat by reducing the joint (using supination-flexion or hyperpronation); a subtle palpable pop or click is often detected when the radial head resumes its normal position.
