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Clinical Procedures > Musculoskeletal Procedures
Joint Reduction, Radial Head Subluxation
Article Last Updated: Apr 2, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Gretchen S Lent, MD, Assistant Professor, Montefiore Medical Center department of Emergency Medicine, Albert Einstein College of Medicine
Editors: Andrew K Chang, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Attending Physician, Windham Memorial Community Hospital; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
radial head subluxation, elbow dislocation, elbow injury, nursemaid’s elbow, subluxation of the radial head, pulled elbow, upper extremity injury, young children, joint reduction, elbow injury
Radial head subluxation, also known as nursemaid's elbow, is the most common upper extremity injury in infants and young children who present to the emergency department (ED). Reduction of the radial head is easily performed in the ED with few complications.
Subluxation of the radial head is a minor injury in infants and children aged 6 months to 7 years. While subluxation does occur in patients younger than 6 months, peak incidence occurs in children aged 2-3 years, and the injury is rare in children older than 5 years. This injury typically results from a quick pull on a child's arm.
Subluxation occurs after longitudinal traction is placed on a pronated extended arm.
The annular ligament is generally weak in young children. Thus, when longitudinal traction is placed on an extended pronated arm, the radial head may slip into the radiocapitellar articulation, resulting in subluxation. The left arm is more commonly involved, presumably because most caretakers are right-handed. Girls are affected more often than boys.
A child with a radial head subluxation presents in no distress, with the affected arm semiflexed, adducted, and pronated.
The subluxed arm is held semiflexed, adducted, and pronated.
Parents often note that the child is not using or bending the affected arm. Radiograph findings are often normal, and radiographs are usually not necessary if radial head subluxation is suspected. However, the positioning required to take proper radiographs often reduces the radial head into place. The lateral elbow may have mild tenderness, and attempts to pronate or supinate the arm cause pain. All other range of motion is often permitted. No significant edema or effusion should be found on clinical examination.
The diagnosis is mostly supported by a child holding the elbow slightly flexed and pronated and a lack of ecchymosis or edema to the affected joint.
- A diagnosis other than radial head subluxation should be sought if the history includes trauma to the arm, swelling, point tenderness, deformity, or ecchymosis to the patient's elbow.
Alternative diagnoses should be sought if point tenderness or any obvious deformity is present.
- Patients with known congenital lesions or neurologic deficits require a more detailed evaluation.
- Reduction of a subluxed radial head is generally a quick and easy procedure that requires no anesthesia. Acetaminophen or ibuprofen may be given to a child for pain relief.
- In special situations, procedural sedation may be used; however, the risks usually outweigh the benefits in routine reductions.
No equipment is necessary for this joint reduction.
The patient stands or sits on the caregiver's lap for comfort and support during radial head reduction. The physician faces the patient and sits or kneels to be at the same eye level as the patient.
Two methods are popular for reducing a subluxed radial head: the supination technique and the hyperpronation technique.
With either technique, a palpable or audible click is associated with a high probability of successful reduction. Once the radial head is reduced, the child's pain and apprehension often immediately resolve. The patient should be observed every 5 minutes for resolution of symptoms. The child usually begins to use the arm immediately, though some children may take up to 30 minutes to use the affected arm.
The time from reduction to normal arm use is increased in younger patients and in those whose subluxations have been present for more than 12 hours. A 24-hour sling may be placed on the elbow for comfort; however, this is not necessary for most patients. Occasionally, symptoms may last for several days and a sling may be worn for longer. Recurrence of such an injury may be avoided by instructing parents and caregivers not to pull children by their arms.
Supination technique
- This is the classic method of reduction.
- Begin with the arm in pronation and the elbow in 90 degrees of flexion.
For the supination technique, begin with the elbow flexed.
- Place a thumb over the patient's radial head.
Hold the elbow in 90 degrees of flexion with a thumb on the radial head.
- Next, firmly supinate the wrist, keeping a thumb on the radial head.
Supinate the wrist with the elbow still in 90 degrees of flexion.
While supinating, keep a thumb on the radial head.
- Then, flex the elbow completely. A click is often felt over the radial head when the arm has reached full supination.
Once supinated, fully flex the elbow.
With one hand supinating the wrist, the other thumb feels a click as the radial head falls into place on full flexion.
To perform the supination technique, begin with supination, then fully flex at the elbow.
Supination technique, side view.
Supination technique, front view.
- This technique has an 80-92% success rate.
Hyperpronation technique - This method is emerging as the recommended technique of reduction.
- Hold the patient's elbow in 90 degrees of flexion. Next, firmly pronate the wrist.
Hyperpronate the arm.
Hyperpronation technique, side view.
Hyperpronation technique, front view.
- This technique tends to be more successful on initial and repeated reduction attempts and is shown to be more successful for left-sided injuries. Evidence has shown that hyperpronation is less painful than supination. The hyperpronation technique has been advocated as the first-line reduction maneuver.
- Some practitioners advocate teaching the parents or caregivers how to reduce a subluxed radial head in case of recurrences.
- As with any injury, document the neurologic and vascular status before and after manipulation.
- If the above reduction techniques do not result in normal function within 30 minutes, consider an alternative diagnosis.
- About 2-4 reduction attempts may be made 15 minutes apart, after which a radiograph should be obtained to look for fractures or other complications.
- If 1 technique fails initially, the other may be attempted.
- If multiple reduction attempts prove unsuccessful, a posterior splint can be placed and the child can be referred to an orthopedist.
- As many as 27% of patients experience recurrence, which may be treated with immobilization.
- Rare complications include fractures that result from reduction or required operative repair of the subluxation.
Upon presentation of any injured child, the physician must consider possible abuse, especially in cases of recurrent subluxation.
Media file 1:
Subluxation occurs after longitudinal traction is placed on a pronated extended arm.
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Media file 2:
The subluxed arm is held semiflexed, adducted, and pronated.
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Alternative diagnoses should be sought if point tenderness or any obvious deformity is present. |
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For the supination technique, begin with the elbow flexed.
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Hold the elbow in 90 degrees of flexion with a thumb on the radial head. |
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Supinate the wrist with the elbow still in 90 degrees of flexion. |
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While supinating, keep a thumb on the radial head.
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With one hand supinating the wrist, the other thumb feels a click as the radial head falls into place on full flexion. |
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To perform the supination technique, begin with supination, then fully flex at the elbow. |
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With one hand distally, hyperpronate the arm while the other hand holds the elbow steady with the thumb on the radial head. |
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Shortly after reduction, the child resumes using the affected arm. |
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Supination technique, side view. |
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Supination technique, front view. |
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Hyperpronation technique, side view. |
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| Media file 17:
Hyperpronation technique, front view. |
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- Bretland PM. Pulled elbow in childhood. Br J Radiol. Dec 1994;67(804):1176-85. [Medline].
- Choung W, Heinrich SD. Acute annular ligament interposition into the radiocapitellar joint in children (nursemaid's elbow). J Pediatr Orthop. Jul-Aug 1995;15(4):454-6. [Medline].
- Hay W. Current Pediatrics. 17th ed. New York, NY: McGraw-Hill; 2005.
- Hutchinson J. Partial dislocation of the head of the radius peculiar to children. Br Med J. 1886;1:9-10.
- Illingworth CM. Pulled elbow: a study of 100 patients. Br Med J. Jun 21 1975;2(5972):672-4. [Medline].
- Lewis D, Argall J. Reduction of pulled elbows. Emerg Med J. Jan 2003;20(1):61-2. [Medline].
- Lyver MB. Radial head subluxation. J Emerg Med. May-Jun 1991;9(3):154-6. [Medline].
- Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. Jul 1998;102(1):e10. [Medline].
- Macias CG, Wiebe R, Bothner J. History and radiographic findings associated with clinically suspected radial head subluxations. Pediatr Emerg Care. Feb 2000;16(1):22-5. [Medline].
- McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med. Jul 1999;6(7):715-8. [Medline].
- Nichols J. Nursemaid's elbow: reducing it to simple terms. Contemp Pediatr. 1988;5:50-55.
- Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child. Dec 1985;139(12):1194-7. [Medline].
- Sacchetti A, Ramoska EE, Glascow C. Nonclassic history in children with radial head subluxations. J Emerg Med. Mar-Apr 1990;8(2):151-3. [Medline].
- Salter RB, Zaltz C. Anatomic investigations of the mechanism of injury and pathologic anatomy of "pulled elbow" in young children. Clin Orthop Relat Res. 1971;77:134-43. [Medline].
- Schunk JE. Radial head subluxations: Epidemiology and treatment of 87 episodes. Ann Emerg Med. 1990;19:1019-1023. [Medline].
- Schutzman SA, Teach S. Upper extremity impairment in young children. Ann Emerg Med. 1995;26:474-479.
- Snellman O. Subluxation of the head of the radius in children. Acta Orthop Scand. 1959;28:311-5. [Medline].
- Tintinalli, Kelen, Stapczynski. Emergency Medicine: A comprehensive Study guide. 6th ed. New York, NY: McGraw-Hill; 2004.
- Way L, Doherty G. Current Surgical Diagnosis and Treatment. 11th ed. New York, NY: McGraw-Hill; 2003.
Joint Reduction, Radial Head Subluxation excerpt Article Last Updated: Apr 2, 2007
Topic originally published: Mar 29, 2007
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