Radial head dislocation (traumatic)

Pulled elbow/nursemaid's elbow/radial head subluxation

Nursemaid's elbow is a radial head subluxation caused by axial traction on the extended arm while the forearm is pronated, allowing for slippage of the radial head under the annular ligament

• may occur when a child is pulled at the wrist to prevent a fall or picked up from the floor by their hand
  • type of injury typically occurs in children between 1 and 4 years of age with a slight predominance in females (1)
  • represents more than 20% of upper extremity injuries in children (3)
  • left arm is more commonly affected than the right (3)
    
    
• is very rare for there to be an isolated dislocation of the radial head
  • a concurrent fracture of the ulna should be suspected (Monteggia fracture dislocation). Also one should suspect shortening of the ulna due to bone dysplasia
    
    
• in a child, there may be a history of the patient being pulled abruptly by the hand or swung by its parents. For this reason, the condition may be described as "pulled elbow"
  
  
• mainstay of treatment is conservative with reduction by flexion and supination or hyperpronation (1)
  
  
• if left neglected, this may cause permanent functional disability of the elbow
  
  
• in rare cases, subluxation may lead to osteochondritis dissecans of the radial head (1)

Management:

• in a child
  • reduction procedure can easily be done in the office setting, with an 80% success rate and no complications (2)
    • the hyperpronation maneuver (holding the elbow at 90° and then firmly pronating the wrist) to reduce pulled elbow has been found to be better than a supination-flexion maneuver (holding the elbow at 90° with one hand, supinating and flexing the elbow rapidly with the other) and should be exercised first
    • has been shown that immobilising the elbow for 2 days after the reduction improves the success of treatment for a pulled elbow and reduces the risk of recurrence (1)
    • if reduction was successful, no splinting or sling is necessary, and the prognosis is excellent (3)
      • because of possible recurrence, parents should be instructed to avoid activities that cause axial traction to the arm such as lifting, jerking or swinging the child by the hands, wrists or forearms
        
        
• in an adult, surgical reconstruction of the ligaments and wire fixation are usually required. Any cause for the dislocation, such as a fracture of the ulna, should be corrected

Reduction is impossible if there is concomitant shortening of the ulna and the abnormality must be accepted.

Reference:

• Mohd Miswan MF, Othman MS, Muhamad Effendi F, Ibrahim MI, Rozali KN. Pulled/nursemaid's elbow. Malays Fam Physician. 2017 Apr 30;12(1):26-28.
• Yamanaka S, Goldman RD. Pulled elbow in children. Can Fam Physician. 2018 Jun;64(6):439-441.
• Nardi NM, Schaefer TJ. Nursemaid Elbow. [Updated 2022 Aug 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430777/