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Radial Head Subluxation (Nursemaid’s Elbow)

Radial head subluxation, also known as nursemaid’s elbow or babysitter’s elbow, is a frequent injury seen in children under 4 years of age and describes the subluxation of the radial head under the annular Annular Dermatologic Examination ligament at the elbow. The injury primarily occurs when a child is pulled, swung, or lifted by 1 arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present holding their injured upper limb in a guarded and pronated position. Diagnosis is made clinically and the condition is managed by a closed-reduction maneuver. Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual's condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas is excellent when diagnosed in a timely manner.

Last updated: Dec 5, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Radial head subluxation, also known as nursemaid’s elbow or babysitter’s elbow, describes the subluxation of the radial head under the annular Annular Dermatologic Examination ligament due to longitudinal traction on the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy.

Epidemiology

  • Affects 20,000 children per year in the United States
  • Most commonly occurs in children aged 1–4 years 
  • Most common upper limb injury in children < 6 years of age
  • The left arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy tends to be injured more often.
  • Girls are more commonly affected.

Related videos

Pathophysiology

Radial head subluxation occurs when the child is lifted up by the arms with resultant axial Axial Computed Tomography (CT) traction of the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy; e.g., while the child is being swung, lifted, or pulled by 1 arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy

Axial Axial Computed Tomography (CT) traction mechanism:

  • Pronated forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy undergoes axial Axial Computed Tomography (CT) traction while the elbow is extended.
  • With axial Axial Computed Tomography (CT) traction, the head of the radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy slips under the annular Annular Dermatologic Examination ligament.
  • The annular Annular Dermatologic Examination ligament becomes interposed between the capitellum and the radial head.
  • As children age, the annular Annular Dermatologic Examination ligament thickens and nursemaid’s elbow becomes less likely to occur.

Other possible mechanisms:

  • Falling onto outstretched arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy
  • Twisting of forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy
Difference normal elbow and nursemaid’s elbow

Difference between a normal elbow and a nursemaid’s elbow

Image by Lecturio. License: CC BY-NC-SA 4.0

Clinical Presentation and Diagnosis

History

History and presentation often lead to the diagnosis:

  • Young toddler refusing to use arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy
  • Often associated with history of longitudinal traction:
    • Young child moves suddenly in opposite direction while holding adult’s hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy.
    • Young child is lifted up by arms.

Physical examination

The entire affected upper limb/ clavicle Clavicle A bone on the ventral side of the shoulder girdle, which in humans is commonly called the collar bone. Clavicle Fracture should be examined.

  • Patient is often anxious and protective of injured arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy.
  • Injured upper limb is held in slightly flexed, pronated position.
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are unable or unwilling to supinate their arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy.
  • Signs of trauma (e.g., ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures, edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, warmth) or neurovascular compromise are absent; if present, other diagnoses should be considered.
  • If there is clinical suspicion of child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse, a complete physical examination should be performed.
  • If radial head spontaneously reduces prior to examination, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may be asymptomatic.

Diagnosis

History and physical examination with typical findings are sufficient to diagnose. Imaging may be useful when diagnostic challenges occur with atypical presentations or unknown history.

X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests

  • Rarely indicated with typical presentation
  • Useful in evaluation of other diagnoses (e.g., fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, congenital Congenital Chorioretinitis elbow dislocation Elbow dislocation Elbow dislocation is the displacement of either the radius or the ulna relative to the humerus. The most common mechanism of injury is falling on an outstretched hand. Elbow dislocation presents with joint swelling, pain, and restricted range of motion. Elbow Dislocation, infectious etiology)
  • A Salter-Harris type I fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of distal humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy may present with normal radiographs.

Management and Prognosis

Management

Closed reduction of a nursemaid’s elbow is the procedure of choice. The clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship must be certain there are no fractures prior to manipulation.

Supination Supination Applies to movements of the forearm in turning the palm forward or upward. When referring to the foot, a combination of adduction and inversion movements of the foot. Examination of the Upper Limbs/ flexion Flexion Examination of the Upper Limbs technique:

  • Warn caregivers that the maneuver will hurt and the child will likely cry.
  • Child can be seated in parent’s or caregiver’s lap.
  • Fully extend and supinate elbow and then take elbow into flexion Flexion Examination of the Upper Limbs.
  • This procedure is done while maintaining slight pressure over the radial head; often, the provider will feel a “click” in the elbow.
  • Typically, the child will be moving the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy normally within 15 minutes.
Supination flexion technique

Supination Supination Applies to movements of the forearm in turning the palm forward or upward. When referring to the foot, a combination of adduction and inversion movements of the foot. Examination of the Upper Limbs/ flexion Flexion Examination of the Upper Limbs technique

Image by Lecturio.

Hyperpronation technique:

  • Warn caregivers that the maneuver will hurt and the child will likely cry.
  • Child can be seated in parent’s or caregiver’s lap.
  • While applying mild pressure over the radial head, the provider holds the elbow in a flexed position and hyperpronates the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy.
  • A click may be felt when displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms is reduced.
  • Typically, the child will be moving the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy normally within 15 minutes.
Hyperpronation technique

Hyperpronation technique

Image by Lecturio.

Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who fail the initial reduction maneuver:

  • Reconsider the diagnosis.
  • If there are no signs of fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, reduction attempt may be repeated.
  • If unable to reduce or if diagnosis is in question, consider a splint and orthopedic referral.

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas is excellent when reduced in a timely manner.
  • Recovery is immediate after reduction.
  • Recurrence rate: approximately 20%

Differential Diagnosis

  • Child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse: an act or failure to act that results in harm to a child’s health or development. Child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse encompasses neglect Neglect Child Abuse as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse is a cause of significant morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status and mortality Mortality All deaths reported in a given population. Measures of Health Status in the pediatric population. 
  • Greenstick fracture Greenstick fracture The bones of growing children exhibit unique characteristics, which, combined with the unique mechanisms of injury seen in children, result in fracture patterns differing significantly from those common in adults. The greenstick fracture is an incomplete fracture usually seen in long bones. Greenstick Fracture: partial-thickness fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures that involves a complete break of cortex and periosteum Periosteum Thin outer membrane that surrounds a bone. It contains connective tissue, capillaries, nerves, and a number of cell types. Bones: Structure and Types on only 1 side of the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types. Termed “greenstick” as it resembles the break in a live, “green” twig, where 1 side of the stick remains intact. High risk for refracture and therefore should be completely immobilized. Rarely requires reduction, but should be managed cautiously to prevent malunion Malunion Hip Fractures or angulation Angulation Buckle or Torus Fracture deformities, and often should be referred for orthopedic follow-up.
  • Buckle or torus fracture Buckle or Torus Fracture The bones of growing children exhibit unique characteristics. These characteristics, combined with the unique mechanisms of injury seen in children, result in fracture patterns that differ significantly from those that are common in adults. Buckle or Torus Fracture: fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures affecting growing metaphyseal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types secondary to compression Compression Blunt Chest Trauma load, where bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types buckles or compresses. Generally considered a stable fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures. Treated by immobilization Immobilization Delirium and has good a prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas.
  • Supracondylar fracture Supracondylar fracture Supracondylar fractures are the most common elbow fractures in the pediatric population. The most common mechanism of injury involves a fall on an outstretched hand, resulting in a fracture of the distal humerus. Patients frequently present with pain, visible deformity, and limited range of motion of the injured elbow. Supracondylar Fracture: complete fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures affecting distal humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy after falling on outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy. Commonly fractures of the elbow in children. Requires immediate orthopedic consultation, as many cases are associated with neurovascular injury and require surgical intervention. 

References

  1. Nardi, N. M., Schaefer, T. J. (2021). Nursemaid elbow. StatPearls. Retrieved May 10, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK430777/
  2. Welch, R., Chounthirath, T., Smith, G. A. (2017). Radial Head Subluxation Among Young Children in the United States Associated With Consumer Products and Recreational Activities. Clin Pediatr (Phila). 56(8), 707–715. https://pubmed.ncbi.nlm.nih.gov/28589762/
  3. Macias, C. G., Bothner, J., Wiebe, R. (1998). A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 102(1), e10. https://pubmed.ncbi.nlm.nih.gov/9651462/
  4. Genadry, K. C., et al. (2021). Management and Outcomes of Children With Nursemaid’s Elbow. Ann Emerg Med. 77(2), 154–162. https://pubmed.ncbi.nlm.nih.gov/33127100/

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