CHAPTER 194 Nursemaid’s Elbow Radial Head Subluxation Russell D. White, Christopher F. Adams Nursemaid’s elbow (radial head subluxation [RHS]) or “pulled elbow” is a common injury to children under 7 years old. The mechanism of injury is usually sudden axial traction of the outstretched, pronated forearm. It often occurs when a parent picks the child up and suspends the child’s entire weight while holding only their hands. Alternatively, the child may have asked to be “swung around” while holding their hands. At times, the injury occurs unobserved by an adult. Regardless of mechanism, the child initially complains of pain and then refuses to use the arm. The concerned parents then take the child to seek medical attention. The elbow consists of the articulation of the humerus, ulna, and radial head. The radius and ulna flex and extend against the humerus; the radial head can also rotate against the ulna and capitellum (humerus) to permit forearm pronation and supination. The radial head is held in place against the proximal ulna and capitellum by the annular ligament and joint capsule. In infants and young children, sudden traction on the distal forearm is sometimes more than the annular ligament can sustain; consequently, the radial head slides distally and partially dislocates or “subluxes.” Presumably the annular ligament or synovial tissue becomes interposed between the radial head and capitellum, causing discomfort and preventing the radial head from spontaneous reduction. Diagnosis Often the history suggests the diagnosis. Typical scenarios for radial head subluxation include a caregiver pulling a child out of harm’s way, a reluctant child being pulled along by the hand, a child suddenly dropping to the floor while being held, or a child being swung playfully by the arms. It is not uncommon for the subluxion to occur unwitnessed; in that case, the child may provide the history of having fallen or rolled over in bed. At presentation, the child expresses acute pain, refuses to move the affected extremity, and holds the elbow in a pronated and slightly flexed position (the nursemaid’s position). Examination reveals no deformity and little if any swelling around the elbow. (Having the parent question the child and examine for areas of tenderness, with the clinician’s guidance, may be less threatening than examination by the unknown clinician.) The child resists range of motion at the elbow, including further flexion or extension as well as supination and further pronation. Some tenderness is noted over the radial head, but not the supracondylar regions. Neurovascular compromise is rare with this injury. Not infrequently, a child will have no known traction injury but holds the arm against the chest, refuses to use the arm, and has no significant deformity, swelling, or neurovascular compromise. The absence of a classic history of axial traction does not rule out the diagnosis of radial head subluxation. A small retrospective study found that a third of the 45 cases of nursemaid’s elbow in the emergency department did not have a history of axial traction. Radiographic Studies The clinician should take standard elbow radiographs, including three views (anteroposterior, lateral, and oblique). Comparison radiographs of the contralateral elbow are essential in the young child because incomplete ossification increases the difficulty in evaluating the immature elbow structures and alignment. Radiographs of nursemaid’s elbow are usually normal or reveal longitudinal misalignment of the radial head with the capitellum. The subluxation is occasionally reduced by the technician when taking the radiographs; the child is often distracted while being positioned for three radiographs and this may allow the elbow to be supinated and flexed. The child then returns to the clinical area using the affected extremity. The clinician should evaluate the radiographs for the presence of a “fat pad sign” (joint effusion), location and alignment of epiphyseal growth centers, and the longitudinal alignment of the radial head with the capitellum. The fat pad sign is positive if a radiolucent stripe is visible at the posterior distal aspect of the humerus on the lateral view of the elbow and not visible on the comparison view. The periarticular fat is displaced posteriorly by an increase in intra-articular joint fluid, making it visible in the lateral view. This is a nonspecific finding. A positive fat pad sign associated with a history of trauma suggests a bloody joint effusion and intra-articular injury. In this case immediate orthopedic referral is recommended. A nursemaid’s elbow can still be present despite the absence of a fat pad sign; in fact, that is generally the rule. Misalignment of the ossification centers suggests a growth plate injury. Orthopedic referral is recommended for growth plate injury or other obvious fracture. Elbow fractures have a high complication rate. We would never recommend manipulation of the patient, even with classic symptoms, before a radiographic study has been performed, although some clinicians do. Indications A child holding his or her arm in a pronated, partially flexed position, refusing to use it, often with a history of axial traction compatible with radial head subluxation (but not always), and negative radiographs indicates nursemaid’s elbow. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Like this:Like Loading... 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CHAPTER 194 Nursemaid’s Elbow Radial Head Subluxation Russell D. White, Christopher F. Adams Nursemaid’s elbow (radial head subluxation [RHS]) or “pulled elbow” is a common injury to children under 7 years old. The mechanism of injury is usually sudden axial traction of the outstretched, pronated forearm. It often occurs when a parent picks the child up and suspends the child’s entire weight while holding only their hands. Alternatively, the child may have asked to be “swung around” while holding their hands. At times, the injury occurs unobserved by an adult. Regardless of mechanism, the child initially complains of pain and then refuses to use the arm. The concerned parents then take the child to seek medical attention. The elbow consists of the articulation of the humerus, ulna, and radial head. The radius and ulna flex and extend against the humerus; the radial head can also rotate against the ulna and capitellum (humerus) to permit forearm pronation and supination. The radial head is held in place against the proximal ulna and capitellum by the annular ligament and joint capsule. In infants and young children, sudden traction on the distal forearm is sometimes more than the annular ligament can sustain; consequently, the radial head slides distally and partially dislocates or “subluxes.” Presumably the annular ligament or synovial tissue becomes interposed between the radial head and capitellum, causing discomfort and preventing the radial head from spontaneous reduction. Diagnosis Often the history suggests the diagnosis. Typical scenarios for radial head subluxation include a caregiver pulling a child out of harm’s way, a reluctant child being pulled along by the hand, a child suddenly dropping to the floor while being held, or a child being swung playfully by the arms. It is not uncommon for the subluxion to occur unwitnessed; in that case, the child may provide the history of having fallen or rolled over in bed. At presentation, the child expresses acute pain, refuses to move the affected extremity, and holds the elbow in a pronated and slightly flexed position (the nursemaid’s position). Examination reveals no deformity and little if any swelling around the elbow. (Having the parent question the child and examine for areas of tenderness, with the clinician’s guidance, may be less threatening than examination by the unknown clinician.) The child resists range of motion at the elbow, including further flexion or extension as well as supination and further pronation. Some tenderness is noted over the radial head, but not the supracondylar regions. Neurovascular compromise is rare with this injury. Not infrequently, a child will have no known traction injury but holds the arm against the chest, refuses to use the arm, and has no significant deformity, swelling, or neurovascular compromise. The absence of a classic history of axial traction does not rule out the diagnosis of radial head subluxation. A small retrospective study found that a third of the 45 cases of nursemaid’s elbow in the emergency department did not have a history of axial traction. Radiographic Studies The clinician should take standard elbow radiographs, including three views (anteroposterior, lateral, and oblique). Comparison radiographs of the contralateral elbow are essential in the young child because incomplete ossification increases the difficulty in evaluating the immature elbow structures and alignment. Radiographs of nursemaid’s elbow are usually normal or reveal longitudinal misalignment of the radial head with the capitellum. The subluxation is occasionally reduced by the technician when taking the radiographs; the child is often distracted while being positioned for three radiographs and this may allow the elbow to be supinated and flexed. The child then returns to the clinical area using the affected extremity. The clinician should evaluate the radiographs for the presence of a “fat pad sign” (joint effusion), location and alignment of epiphyseal growth centers, and the longitudinal alignment of the radial head with the capitellum. The fat pad sign is positive if a radiolucent stripe is visible at the posterior distal aspect of the humerus on the lateral view of the elbow and not visible on the comparison view. The periarticular fat is displaced posteriorly by an increase in intra-articular joint fluid, making it visible in the lateral view. This is a nonspecific finding. A positive fat pad sign associated with a history of trauma suggests a bloody joint effusion and intra-articular injury. In this case immediate orthopedic referral is recommended. A nursemaid’s elbow can still be present despite the absence of a fat pad sign; in fact, that is generally the rule. Misalignment of the ossification centers suggests a growth plate injury. Orthopedic referral is recommended for growth plate injury or other obvious fracture. Elbow fractures have a high complication rate. We would never recommend manipulation of the patient, even with classic symptoms, before a radiographic study has been performed, although some clinicians do. Indications A child holding his or her arm in a pronated, partially flexed position, refusing to use it, often with a history of axial traction compatible with radial head subluxation (but not always), and negative radiographs indicates nursemaid’s elbow. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Like this:Like Loading... 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