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Radial Head Subluxation

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Topic updated on 11/14/17 6:37pm

Overview
 

 
Snapshot
  • A 4-year-old boy presents to the pediatrician with elbow pain. He was forcefully pulled onto the curb by his mother after nearly getting hit by an oncoming car. Since the incident, the child has presented with right elbow pain and has refused to move his right arm. Examination reveals an irritable child cradling his right upper limb with his left hand. The affected limb is pronated with the elbow slightly flexed. Radiographs reveal subluxation of the radial head but are otherwise negative for a fracture. 
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 examination
    • 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 post
      • 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 fo 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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Qbank (1 Questions)

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(M2.OR.20) You are in the emergency department seeing a 3-year-old girl who presents with elbow pain. Approximately one hour prior to presentation, the patient was walking with her mother, when she started to run across the street toward her friends who were playing in the yard. Noticing a car coming, the patient's mother quickly grabbed the patient's left arm and pulled her back sharply. The patient immediately began to cry, and is currently holding her arm across her stomach with her palm facing down. Radiographs of her elbow are unremarkable. What is the most appropriate next step? Topic Review Topic

1. Immediate casting
2. Urgent surgery
3. Flexion and supination of the forearm
4. Extension and supination of the forearm
5. Expectant management

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