Radial Head Subluxation and Associated Complications

1
Radial Head Subluxation and Associated
Complications

• Aimee Disharoon
• December 14, 2005

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Radial Head Subluxation

• AKA Nursemaids Elbow
• Common injury that is seen most often in children
  between the ages of 1-6 years
• Occurs when longitudinal traction is placed on
  the hand while the elbow is extended and the
  forearm pronated.
• Usually occurs when child falls and continues to
  be held by the hand, or when small children are
  swung by their arms.

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Anatomy

• 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 because at an
  early age, the radial head is spherical and is
  composed mainly of cartilage

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Clinical Presentation

• history of arm being pulled
• injured elbow pronated, partially flexed and held
  by side, child will not use
• there is anterolateral tenderness over the radial
  head
• no swelling, redness, warmth, abrasions, or
  ecchymosis
• have been reports of infants lt 6 months old with
  a history of not using arm after rolling over and
  their arms getting caught

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Radiographs

• Diagnosis is by history and physical examination.
  Radiograph examination is usually not necessary
  and are normal in most instances.
• If x-rays are taken, often the subluxation is
  reduced when the technician positions the arm on
  the plate.
• Radiographs become necessary if pain continues
  post-reduction.

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Reduction

• Cup affected elbow with opposite hand
• Apply pressure over radial head
• Thumb in antecubital fossa
• Apply slight longitudinal traction by grasping
  wrist
• Supinate (palm up) and flex (to 90 degrees)
  forearm
• Palpable click felt with reduction

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Post-reduction Management

• Child should be pain-free and use arm within
• 0-15 minutes. Immobilization optional (Sling
  for 1-2 days)
• If child fails to use arm after 15 minutes,
  obtain elbow views to rule out concomitant
  fracture
• If x-rays normal but child still not using arm,
  use a posterior splint and sling and re-evaluate
  in 24 hours
• If child has 3 recurrent episodes of subluxation,
  then apply hard cast for 3 weeks

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Elbow X-ray

• Views
• AP
• Oblique
• Lateral
• Technique
• Elbow in 90 degree flexion
• Compare with opposite elbow

• Evaluation
• The radial head should always point at the
  capitellum in all views. A line drawn down the
  long axis of the radius (radial head) should
  intersect the capitellum in all views (if the
  line doesnt intersect, this is a sign of
  dislocation)

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Complications

• If pain does not subside post-reduction, then
  suspect fracture (x-rays required)
• Supracondylar Fracture /Salter-Harris Fracture
• Monteggia Fracture
• Green Stick Fracture

Fractures can be seen as lines tranversing the
bone, displace-ment of one end of bone relative
to the other end, and as joint effusions or fat
pads
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Supracondylar Fracture

• True supracondylar fractures typically occur just
  above the humeral epicondyles
• Salter-Harris fractures occur in the epiphysis of
  the humerus, are subtle and often hard to
  differentiate from dislocations (line drawn
  through the radius intersects with capitellum)

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Monteggia Fracture

• Fracture of the proximal third of ulna with
  radial head dislocation

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Green Stick Fracture

• Incomplete fracture of the radius or ulna which
  causes bowing of the bone

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References

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