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Radial Head Subluxation

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Topic updated on 11/17/17 2:39pm

Overview
 

 
Snapshot
  • A 5-year-old child presents to the pediatrician with severe left elbow pain. His mother explains that the pain started after she suddenly pulled him away from the curb. The child's arm is held in slight flexion and pronation.
Introduction
  • Clinical definition
    • subluxation (partial dislocation) of the radial head relative to the radiocapitellar joint
      • also known as Nursemaid elbow
  • Epidemiology
    • incidence
      • second most common serious elbow injury in children after supracondylar fractures 
    • demographics
      • most common in children between 2-5 years of age
  • Etiology
    • traumatic injury
      • commonly due to excess longitudinal traction on a child's arm
        • e.g., a parent pulling vigorously on child's arm
  • Pathoanatomy
    • normal anatomy of the elbow
      • 3 joints
        • radiocapitellar joint
          • radial head articulates with the humeral capitellum
        • ulnohumeral joint
          • trochlear notch of the ulna articulates with the humeral trochlea
        • proximal radioulnar joint
          • radial head articulates with the radial notch of the ulna
      • 2 ligamentous stabilizers
        • lateral collateral ligament (LCL) complex
          • contains the annular ligament, a proximal radioulnar joint stabilizer
        • medial collateral ligament (MCL) complex
    • mechanism of injury
      • longitudinal traction applied to an extended arm leads to
        • subluxation (partial dislocation) of the radial head inferiorly
        • interposition of the annular ligament into the radiocapitellar joint
Presentation
  • Symptoms
    • lateral elbow pain
    • child will hold the elbow in slight flexion and the forearm pronated
  • Physical exam
    • pain and tenderness localized to the lateral aspect of the elbow
Imaging
  • Radiographs
    • indication
      • not routinely indicated given a strong clinical history and exam unless other bony conditions (e.g., elbow fractures) need to be ruled out
    • findings
      • normal radiographs in patients with radial head subluxation
Treatment
  • Conservative
    • closed reduction of the radial head
      • indication
        • nearly all cases will resolve with closed reduction
      • technique
        • supination of the forearm with the elbow in slight flexion
Differential
  • Supracondylar humerus fracture 
    • distinguishing factors
      • typically caused by fall on outstretched hand instead of excess traction
      • will demonstrate evidence of fracture on radiography
  • Lateral condylar fracture
    • distinguishing factors
      • typically caused by fall on outstretched hand instead of excess traction
      • will demonstrate evidence of fracture on radiography
Complications
  • Recurrence
    • occurs in 5-39% of cases but generally ceases after 5 years of age


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