Radial head subluxation

Background

• Radial head subluxation due to longitudinal traction on arm
  • Annular ligament of radius displaces into radiocapitellar articulation
• Age 1y-5y (peak 2y-3y)

Clinical Features

• Sudden onset
• Typical history: Sudden pull on extended arm. Swinging the child by adult while playing.
• Absence of edema, focal tenderness, or bruising

Differential Diagnosis

Elbow Diagnoses

Radiograph-Positive

• Distal humerus fracture
• Radial head fracture
  • Essex-Lopresti fracture
• Capitellum fracture
• Olecranon fracture
• Elbow dislocation

Radiograph-Negative

• Biceps tendon rupture/dislocation
• Lateral epicondylitis
• Medial epicondylitis
• Olecranon bursitis (nonseptic)
• Pronator teres syndrome
• Septic bursitis

Pediatric

• Nursemaid's elbow
• Supracondylar fracture
• Lateral epicondyle fracture
• Medial epicondyle fracture
• Olecranon fracture
• Radial head fracture
• Salter-Harris fractures

Evaluation

• If classic history/physical --> proceed directly to reduction maneuver without imaging
• If unclear or atypical history/physical --> consider x-ray first and/or alternative diagnosis

Management

• Reduction: Hyperpronation has greater first try success rate (94% vs 69%), but both have similar overall reduction rate
  • Hyperpronation Technique
    • Hold patient's elbow at 90 degrees with one hand
    • With other hand hyperpronate patient's wrist
  • Supination Technique
    • Hold patient's elbow at 90 degrees with one hand
    • With other hand supinate patient's wrist and flex elbow
• If successful patient will have FROM within 30min
• If unsuccessful after multiple attempts, obtain x-ray
  • If negative, immobilize arm in sling, outpatient ortho follow up within 1wk

Disposition

• If reduced and moving arm, outpatient

See Also

• Elbow diagnoses