Updated: 12/27/2021

Radial Head Subluxation

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  • Snapshot
    • A 4-year-old boy presents to the pediatrician with elbow pain. He was forcefully pulled onto the curb by his mother after nearly getting hit by an oncoming car. Since the incident, the child has presented with right elbow pain and has refused to move his right arm. Examination reveals an irritable child cradling his right upper limb with his left hand. The affected limb is pronated with the elbow slightly flexed. Radiographs reveal subluxation of the radial head but are otherwise negative for a fracture.
  • Introduction
    • Clinical definition
      • subluxation (partial dislocation) of the radial head relative to the radiocapitellar joint
        • also known as Nursemaid elbow
  • Epidemiology
    • Incidence
      • second most common serious elbow injury in children after supracondylar fractures
    • Demographics
      • most common in children between 2-5 years of age
  • Etiology
    • Traumatic injury
      • commonly due to excess longitudinal traction on a child's arm
        • e.g., a parent pulling vigorously on child's arm
    • Pathoanatomy
      • normal anatomy of the elbow
        • 3 joints
          • radiocapitellar joint
            • radial head articulates with the humeral capitellum
          • ulnohumeral joint
            • trochlear notch of the ulna articulates with the humeral trochlea
          • proximal radioulnar joint
            • radial head articulates with the radial notch of the ulna
        • 2 ligamentous stabilizers
          • lateral collateral ligament (LCL) complex
            • contains the annular ligament, a proximal radioulnar joint stabilizer
          • medial collateral ligament (MCL) complex
      • mechanism of injury
        • longitudinal traction applied to an extended arm leads to
          • subluxation (partial dislocation) of the radial head inferiorly
          • interposition of the annular ligament into the radiocapitellar joint
  • Presentation
    • Symptoms
      • lateral elbow pain
      • child will hold the elbow in slight flexion and the forearm pronated
    • Physical examination
      • pain and tenderness localized to the lateral aspect of the elbow
  • Imaging
    • Radiographs
      • indication
        • not routinely indicated given a strong clinical history and exam unless other bony conditions (e.g., elbow fractures) need to be ruled out
      • findings
        • often normal radiographs
  • Treatment
    • Conservative
      • closed reduction of the radial head
        • indication
          • nearly all cases will resolve with closed reduction
        • techniques
          • hyperpronation while elbow is moderately flexed
          • supination of the forearm and then maximal elbow flexion
    • Open reduction
      • rarely necessary
      • may be indicated for chronic, symptomatic subluxations that fail closed reduction
  • Differential
    • Supracondylar humerus fracture
      • distinguishing factors
        • typically caused by fall on outstretched hand instead of excess traction
        • will demonstrate evidence of fracture on radiography
    • Lateral condylar fracture
      • distinguishing factors
        • typically caused by fall on outstretched hand instead fo excess traction
        • will demonstrate evidence of fracture on radiography
  • Complications
    • Recurrence
      • occurs in 5-39% of cases but generally ceases after 5 years of age
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