Dr Furqan Ahmed is an Emergency Medicine middle grade doctor seconded to paediatrics for a few months as part of his training. I hope he is learning from us, we are certainly picking up things from him. He has put together the following guide to “pulled elbow” or “radial head subluxation” for Paediatric Pearls.
Pulled elbow, Nursemaid’s elbow, is a dislocation of the elbow joint caused by a sudden pull on the extended, pronated arm. The technical term for the injury is radial head subluxation.
Pathophysiology:
The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn.
As children age, the annular ligament strengthens, making the condition less common. The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm.
Causes, incidence, and risk factors
Radial head subluxation is a common pediatric presentation generally occurring between the ages of 1 and 4 years, although it can happen anytime between 6 months of age and 7 years. After age 3, children’s joints and ligaments gradually grow stronger, making radial head subluxation less likely to occur.
The injury occurs when a child is pulled up too hard by the hand or wrist. It is often seen after someone lifts a child up by one arm (eg. when trying to lift the child over a curb or high step).
Other ways this injury may happen include:
- Breaking a fall with the arm
- Rolling over in an unusual way
- Swinging a young child from the arms while playing
Signs and symptoms
When the injury occurs, the child usually begins crying right away and refuses to use the arm because of elbow pain.
- The child may hold the arm slightly bent (flexed at 15-20 degrees) at the elbow and pressed up against the abdominal area (pronated).
- The child will move the shoulder, but not the elbow. Some children stop crying as the first pain goes away, but continue to refuse to move the elbow.
- Tenderness at the head of the radius may be present.
- Erythema, warmth, oedema, or signs of trauma are absent.
- Distal circulation, sensation, and motor activity are normal
Treatment
Inform child and caregiver that the reduction may be uncomfortable, but the discomfort will end quickly after reduction. Parents should not attempt these manoeuvres at home unless advised by a physician.
To resolve the problem, the affected arm must be held with one hand/finger on the radial head and the other grasping the hand making sure the elbow is in 90° of flexion. While applying compression between these two hands, the forearm of the patient is gently supinated and the arm flexed. The manipulator will usually feel a “click” if the manoeuvre is done properly, the child will feel momentary pain, and usually within 5 minutes, the forearm will be functioning well and painlessly. NB: although a ‘click’ signifies reduction, absence of a ‘click’ is noted in some successful reductions.
Differential diagnoses:
- Fracture, Elbow
- Fracture, Wrist
- Hand Injury, Soft Tissue
Indication for xray:
Child not using arm 30 minutes after a reduction. External signs of trauma such as swelling, abrasions, or ecchymoses.
Consultations
If radiographic findings demonstrate no fracture, repeat attempts at reduction are unsuccessful, and the child does not regain normal function after 30-40 minutes, the safest management is to support the arm in a sling (or splint and sling) and have the child reevaluated in 1-2 days time.
Prognosis
The prognosis is excellent. Parents can be reassured that no permanent injury results from this condition.
For those who have had one occurrence, the chance of recurrence is approximately 20-25%. Those 24 months and younger may have the greatest risk of recurrence.
References
- ^ Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW (2012). “Manipulative interventions for reducing pulled elbow in young children”. Cochrane Database Syst Rev (1): CD007759. doi:10.1002/14651858.CD007759.pub3. PMID 22258973.
- ^ Toupin P, Osmond MH, Correll R, Plint A (September 2007). “Radial head subluxation: how long do children wait in the emergency department before reduction?”. CJEM 9 (5): 333–7. PMID 17935648. http://www.cjem-online.ca/v9/n5/p333.
- ^ Kaplan, RE; Lillis, KA (2002 Jul). “Recurrent nursemaid’s elbow (annular ligament displacement) treatment via telephone.”. Pediatrics 110 (1 Pt 1): 171–4. PMID 12093966.
- ^ Macias CG, Bothner J, Wiebe R (July 1998). “A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations”. Pediatrics 102 (1): e10. PMID 9651462. http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=9651462.