Radial head subluxation (nursemaid's elbow)
- Brian R Moore, MD
Brian R Moore, MD
- Associate Professor of Emergency Medicine
- University of New Mexico Health Sciences Center
- Joan Bothner, MD
Joan Bothner, MD
- Professor of Pediatrics and Emergency Medicine
- University of Colorado School of Medicine
- Section Editor
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Radial head subluxation (RHS, also called "nursemaid's elbow," "pulled elbow," and "annular ligament displacement") is a common elbow injury that is unique to young children. The diagnosis is usually readily apparent, particularly when the child has a typical mechanism of injury along with no focal findings on physical examination. The displacement is generally easy to reduce.
This topic will review radial head subluxation. Sports-related elbow injuries are discussed separately. (See "Elbow injuries in active children or skeletally immature adolescents: Approach".)
Radial head subluxation is the most common elbow injury in children [1-3]. It typically occurs between the ages of one and four years, with a peak incidence between two and three years [4,5], although cases have been reported in children younger than six months of age and as old as eight years . Girls are more often affected than boys [4,5,7,8], and the left arm is more commonly affected than the right .
The usual mechanism of injury is axial traction on a pronated forearm with the elbow in extension. With sudden traction on the distal radius, a portion of the annular ligament slips over the head of the radius and slides into the radiohumeral joint, where it becomes trapped (figure 1) . The symptoms that develop are the result of displacement of the annular ligament. By the age of five years, the annular ligament has become thick and strong and is unlikely to tear or be displaced.
History — The usual presenting complaint is that the child is not using the affected arm. The typical history is that the forearm was pulled while it was pronated and the elbow was extended. This often occurs as a parent or caregiver grabs the arm to prevent the child from falling or pulling away. Radial head subluxation (RHS) also can occur when a child is swung by the forearms or during play.
- Young GM. Reduction of common joint dislocations and subluxations. In: Textbook of Pediatric Emergency Procedures, Henretig FM, King C. (Eds), Williams & Wilkins, Baltimore 1997.
- Johnson FC, Okada PJ. Reduction of common joint dislocations and subluxations. In: Textbook of Pediatric Emergency Procedures, 2nd ed, Henretig FM, King C, King B, et al. (Eds), Lippincott Williams & Wilkins, Philadelphia 2007. p.962.
- Joffe M, Loiselle J. Musculoskeletal emergencies. In: Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine, 7th ed, Shaw KN, Bachur RG. (Eds), Lippincott Williams and Wilkins, Philadelphia 2015. p.1390.
- Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics 1998; 102:e10.
- Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med 1990; 19:1019.
- Newman J. "Nursemaid's elbow" in infants six months and under. J Emerg Med 1985; 2:403.
- Illingworth CM. Pulled elbow: a study of 100 patients. Br Med J 1975; 2:672.
- Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child 1985; 139:1194.
- Kaplan RE, Lillis KA. Recurrent nursemaid's elbow (annular ligament displacement) treatment via telephone. Pediatrics 2002; 110:171.
- Sacchetti A, Ramoska EE, Glascow C. Nonclassic history in children with radial head subluxations. J Emerg Med 1990; 8:151.
- Macias CG, Wiebe R, Bothner J. History and radiographic findings associated with clinically suspected radial head subluxations. Pediatr Emerg Care 2000; 16:22.
- Snyder HS. Radiographic changes with radial head subluxation in children. J Emerg Med 1990; 8:265.
- Frumkin K. Nursemaid's elbow: a radiographic demonstration. Ann Emerg Med 1985; 14:690.
- McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med 1999; 6:715.
- Green DA, Linares MY, Garcia Peña 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.
- Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev 2012; 1:CD007759.
- Teach SJ, Schutzman SA. Prospective study of recurrent radial head subluxation. Arch Pediatr Adolesc Med 1996; 150:164.
- Thompson GA. Dislocations of the elbow. In: Fractures in Children, 5th, Beaty JH, Kasser JR. (Eds), Lippincott Williams & Wilkins, Philadelphia 2001. p.732.
- CLINICAL FEATURES
- Physical examination
- - Efficacy of reduction maneuvers
- - Hyperpronation method
- - Supination/flexion method
- Postreduction evaluation
- INDICATIONS FOR REFERRAL
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS