Radial Head Subluxation (Nursemaid’s Elbow) Reduction

Simon A. Mahler, MD and Ken Barrick, MD
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Introduction

Radial head subluxation is the most common elbow injury in children. It typically occurs in children between the ages of 1 and 4 with a peak incidence between 2 and 3 years of age. However, nursemaid’s elbow has been reported in children younger than 6 months old and in those up to 8 years of age. Girls are more likely to be affected than boys, and the left arm is more frequently involved than the right. 
Nursemaid’s elbow is typically caused by a sudden axial traction on the child’s arm. This causes a portion of the annular ligament to slip over the radial head into the radiohumeral joint and become trapped. In most children, the annular ligament strengthens by the age of 5, decreasing the likelihood of the injury in older children. 
The classic history suggesting radial head subluxation is that of a “pull injury.” Typically the child’s arm is pulled while the arm is extended to prevent a fall or the child pulling away. This injury also occurs during playful swinging of a child by the arms. This mechanism accounts for approximately 50% of cases. Other less common mechanisms of injury include falling on the elbow, minor direct trauma, or twisting of the arm. Rarely, there is no history of trauma. Children younger than 6 months of age may present with radial head subluxation as a result of the extremity being trapped under the child’s body when rolling over. Nursemaid’s elbow may also be the result of child abuse. 
Children with nursemaid’s elbow present with refusal to move the affected arm. The child typically holds the arm close to the body with the elbow slightly flexed or fully extended and the forearm pronated. The child is usually in no distress until attempts are made to move or examine the arm. With palpation, there may be some tenderness over the anterolateral aspect of the radial head. However, the distal humerus and the ulna are usually not tender. The child will not actively move the involved arm and any attempts to manipulate the extremity will elicit significant discomfort. It is important to examine the entire extremity as well as the clavicle on the affected side to avoid missing other injuries. 
Radial head subluxation is a clinical diagnosis. However, this injury should not be confused with a supracondylar fracture, which presents with focal tenderness and swelling. Radiographs are rarely indicated in radial head subluxation but should be obtained if supracondylar fracture is suspected, the mechanism of injury is inconsistent with the classic history for radial head subluxation, or if multiple attempts at reduction are unsuccessful. 
There are two methods to reduce a radial head subluxation: the supination/flexion method and the hyperpronation method. Both techniques are effective and can be performed in the office or the emergency department. Although supination/flexion method is traditionally suggested, the hyperpronation technique should also be considered first line. Recent studies suggest that the hyperpronation technique is more likely to be successful on the first attempt and is less painful. 
Confirmation of successful reduction occurs when the child voluntarily moves the affected arm. Immediately following reduction, the child may cry and continue to resist arm movement. It may take 5 to 15 minutes before the child moves the affected arm. Following successful reduction, further treatment, immobilization, and activity restriction are not required. 
If the patient is not moving the affected arm at 15 minutes, additional attempts may be made to reduce the joint. Hyperpronation is more successful with second attempts than flexion/supination. If multiple attempts are unsuccessful, radiographs of the arm should be obtained. If the radiographs are normal, the child may be placed in a sling and should have a follow-up arranged. Pediatric orthopedic follow-up should be considered, but next-day office follow-up may suffice. Studies suggest that spontaneous movement within 24 hours is common, occurring in 60% of the patients with failed reduction. Unrecognized or unreduced nursemaid’s elbows have not been linked to any significant clinical sequelae. 

Equipment

  • None

Indications

  • Radial head subluxation (nursemaid’s elbow)

Contraindications

  • Suspected fracture

The Procedure

Step 1

For both techniques, approach the child calmly at eye level to reduce anxiety. The child may be more comfortable in the parent or caretaker’s lap facing toward the clinician. 

Hyperpronation Technique

Step 2
Support the child’s affected arm, maintaining the elbow at 90 degrees. Apply moderate pressure to the radial head. 
Step 3
Grip the forearm with the other hand and pronate the forearm. An audible “click” may be heard, or a “pop” may be felt with successful reduction. 
  • PITFALL: Crepitus or severe pain suggests an occult fracture and requires discontinuation of the procedure.

Supination/Flexion Technique

Step 2
Support the child’s affected arm, keeping the elbow at 90 degrees. Apply moderate pressure to the radial head. 
Step 3
Grasp the hand or wrist as if shaking hands and apply gentle traction. While maintaining traction, supinate the patient’s hand/wrist, then fully flex the affected elbow. An audible “click” may be heard, or a “pop” may be felt with successful reduction. 
  • PITFALL: Crepitus or severe pain suggests an occult fracture and requires discontinuation of the procedure. The hyperpronation technique should be attempted if the supination/flexion technique fails.

Complications

  • Failed reduction

Postprocedure Instructions

It may take 5 to 15 minutes before the child moves the affected arm. Following successful reduction, further treatment, immobilization, and activity restriction are not required. Acetaminophen or ibuprofen can be used for pain as needed. Parents should be informed of reoccurrence risk and avoid pulling their child’s arms. 

Coding Information and Supply Sources

Bibliography

Green DA, Linares MY, Garcia Pena BM, et al. Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. Pediatr Emerg Care. 2006;22:235–238. [View Abstract]
Kaplan RE, Lillis KA. Recurrent nursemaid’s elbow (annular ligament displacement): treatment via telephone. Pediatrics 2002;110:171–174. [View Abstract]
Macias CG, Bonther J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 1998;102:e10–14.
Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child. 1985;139:1194–1197. [View Abstract]
Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med. 1990;19:1019–1023. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’sPhysicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.2007.
 
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