This document discusses radial head subluxation, commonly known as nursemaid's elbow, which occurs most often in children aged 1-6 years when their arm is pulled while the elbow is extended and forearm pronated. It involves the annular ligament slipping over the radial head. Symptoms include refusal to use the arm. Treatment involves gentle reduction by flexing and supinating the forearm. Immobilization may be used and recurrence addressed through casting. Differential diagnoses include fractures that require imaging to rule out.

4. Radial Head SubluxationRadial Head Subluxation
 Common injury that is seen most often inCommon injury that is seen most often in
children between the ages of 1-6 yearschildren between the ages of 1-6 years
 Occurs when longitudinal traction is placed onOccurs when longitudinal traction is placed on
the hand while the elbow is extended and thethe hand while the elbow is extended and the
forearm pronated.forearm pronated.
 Usually occurs when child falls and continues toUsually occurs when child falls and continues to
be held by the hand, or when small children arebe held by the hand, or when small children are
swung by their arms.swung by their arms.

5. AnatomyAnatomy
 The annular ligament normally
passes around the proximal
radius just below the radial
head. With traction on the
extended arm, the annular ligament slides
over the head of the radius into the joint
space and becomes entrapped
 Common early childhood injury becauseCommon early childhood injury because
at an early age, the radial head is sphericalat an early age, the radial head is spherical
and is composed mainly of cartilageand is composed mainly of cartilage

6. Clinical PresentationClinical Presentation
 history of arm being pulledhistory of arm being pulled
 injured elbow pronated, partially flexed and heldinjured elbow pronated, partially flexed and held
by side, child will not use the limb.by side, child will not use the limb.
 there is anterolateral tenderness over the radialthere is anterolateral tenderness over the radial
headhead
 no swelling, redness, warmth, abrasions, orno swelling, redness, warmth, abrasions, or
ecchymosisecchymosis
 have been reports of infants < 6 months oldhave been reports of infants < 6 months old
with a history of not using arm after rolling over.with a history of not using arm after rolling over.

7. normal partial subluxation dislocationsubluxation

8. traction

10. Imaging Studies
 Diagnosis is by history and physicalDiagnosis is by history and physical
examination.examination. Imaging studies are useful in ruling
out possible fracture but are often
unnecessary,and are normal in most instances.and are normal in most instances.
 If x-rays are taken, often the subluxation isIf x-rays are taken, often the subluxation is
reduced when the technician positions the armreduced when the technician positions the arm
on the plate.on the plate.
 Radiographs become necessary if pain continuesRadiographs become necessary if pain continues
post-reduction.post-reduction.

11. Ultrasonography has been used as a
noninvasive modality to assess for
annular ligamentous injury and
displacement of the radial head from
the capitellum. It has also been used
to assess progress of treatment for
patients with recurrent subluxations.
MRI can be used to confirm
subluxation with a ligament tear

12. Treatment
ReductionReduction
 Cup affected elbow withCup affected elbow with
opposite handopposite hand
 Apply pressure over radialApply pressure over radial
headhead
 Thumb in antecubital fossaThumb in antecubital fossa
 Apply slight longitudinalApply slight longitudinal
traction by grasping wristtraction by grasping wrist
 Supinate (palm up) and flexSupinate (palm up) and flex
(to 90 degrees) forearm(to 90 degrees) forearm
 Palpable click felt withPalpable click felt with
reductionreduction

13. Post-reduction ManagementPost-reduction Management
 Child should be pain-free and use arm withinChild should be pain-free and use arm within
0-15 minutes. Immobilization0-15 minutes. Immobilization optionaloptional (Sling for 1-2(Sling for 1-2
days)days)
 If child fails to use arm after 15 minutes, obtain elbowIf child fails to use arm after 15 minutes, obtain elbow
views to rule out concomitant fractureviews to rule out concomitant fracture
 If x-rays normal but child still not using arm, use aIf x-rays normal but child still not using arm, use a
posterior splint and sling and re-evaluate in 24 hoursposterior splint and sling and re-evaluate in 24 hours
 If child has 3 recurrent episodes of subluxation, thenIf child has 3 recurrent episodes of subluxation, then
apply hard cast for 3 weeksapply hard cast for 3 weeks

14. Elbow X-rayElbow X-ray
 Views:Views:
 APAP
 ObliqueOblique
 LateralLateral
 Technique:Technique:
 Elbow in 90 degreeElbow in 90 degree
flexionflexion
 Compare with oppositeCompare with opposite
elbowelbow
 EvaluationEvaluation::
 The radial head shouldThe radial head should
always point at thealways point at the
capitellum in all views. Acapitellum in all views. A
line drawn down the longline drawn down the long
axis of the radius (radialaxis of the radius (radial
head) should intersect thehead) should intersect the
capitellum in all views (ifcapitellum in all views (if
the line doesn’t intersect,the line doesn’t intersect,
this is a sign ofthis is a sign of
dislocation)dislocation)

15. Differential Diagnosis
 If pain does not subsideIf pain does not subside
post-reduction, then suspectpost-reduction, then suspect
fracture (x-rays required)fracture (x-rays required)
•
Fracture, Elbow
•
Fracture, Wrist
•
Hand Injury, Soft Tissue
 Supracondylar FractureSupracondylar Fracture
/Salter-Harris Fracture/Salter-Harris Fracture
 Monteggia FractureMonteggia Fracture
 Green Stick FractureGreen Stick Fracture

16. Supracondylar FractureSupracondylar Fracture
 True supracondylar fracturesTrue supracondylar fractures
typically occur just above thetypically occur just above the
humeral epicondyleshumeral epicondyles
 Salter-Harris fractures occurSalter-Harris fractures occur
in the epiphysis of thein the epiphysis of the
humerus, are subtle and oftenhumerus, are subtle and often
hard to differentiate fromhard to differentiate from
dislocations (line drawndislocations (line drawn
through the radius intersectsthrough the radius intersects
with capitellum)with capitellum)

17. Monteggia FractureMonteggia Fracture
 Fracture of theFracture of the
proximal third of ulnaproximal third of ulna
with radial headwith radial head
dislocationdislocation

18. Green Stick FractureGreen Stick Fracture
 Incomplete fracture ofIncomplete fracture of
the radius or ulna whichthe radius or ulna which
causes “bowing” of thecauses “bowing” of the
bonebone

19. Medication
Once reduced, pain abates, and further therapy is
unnecessary. Persistent pain is inconsistent with
nursemaid elbow and should lead one to reconsider the
diagnosis.
Prevention
Because nursemaid elbow tends to reoccur, families
benefit from counseling. Avoidance of future axial
traction should minimize risk of reoccurrence.

20. ReferencesReferences
 Choung, Walter, and Heinrich,Stephen. AcuteChoung, Walter, and Heinrich,Stephen. Acute
Annunlar Ligament Interposition into theAnnunlar Ligament Interposition into the
Radiocapitellar Joint in Children (Nursemaid's Elbow).Radiocapitellar Joint in Children (Nursemaid's Elbow).
Journal of Pediatric Orthopedics. Vol. 15, No.4 1995Journal of Pediatric Orthopedics. Vol. 15, No.4 1995
 Waander, Hellerstein, and Ballock. Nursemaid's Elbow,Waander, Hellerstein, and Ballock. Nursemaid's Elbow,
Pulling out the Diagnosis. Contemporary Pediatrics.Pulling out the Diagnosis. Contemporary Pediatrics.
June 2000June 2000
 Nursemaid’s Elbow, Familypracticenotebook.comNursemaid’s Elbow, Familypracticenotebook.com
 Riego de Dios, Ricardo, and Norris, Burl. ElbowRiego de Dios, Ricardo, and Norris, Burl. Elbow
Fractures and Dislocations. eMedicine. July 2004Fractures and Dislocations. eMedicine. July 2004