Chapter 143C

The peak incidence of radial head subluxation (nursemaids’ elbow) occurs in children 2 to 3 years of age, with a range from 6 months to 7 years. Girls are seen with the injury more commonly than boys. Left-sided injury is more common, presumably because most caretakers are right-handed. The usual mechanism of injury is sudden longitudinal traction on the arm with the elbow extended, such as occurs when a child is pulled up by the arm, although up to half of injuries are associated with other mechanisms.

In radial head subluxation the annular ligament of the radius displaces into the radiocapitellar articulation. The child will not move the affected arm, but is otherwise not in any distress. The arm is held in an adducted, semiflexed, and prone position. On palpation there is no significant point tenderness or swelling. There may be some discomfort on palpation of the radial head on the affected side. Attempts at pronation and supination of the forearm are painful. Radiographs are not necessary if the clinical suspicion of radial head subluxation is high. There are two maneuvers for reduction, the supination technique and the hyperpronation technique.

To perform the supination technique (Figure 143C-1) hold the child’s elbow at 90 degrees with one hand, then firmly supinate the child’s wrist, and then flex the child’s elbow so that the wrist is directed to the same (ipsilateral) shoulder.

###### Figure 143C-1.

Supination technique. Hold the elbow at 90 degrees, then firmly supinate the wrist and the forearm toward the ipsilateral shoulder.

The hyperpronation technique1 (Figure 143C-2) is reported to be more successful and may be less painful. The technique may be used primarily or as a backup technique when supination fails. Hold the child’s elbow at 90 degrees in one hand, then firmly pronate the child’s wrist.

###### Figure 143C-2.

Hyperpronation technique. Hold the elbow at 90 degrees, then firmly pronate the wrist.

After successful reduction, relief is immediate, and the child is typically moving the affected extremity within 5 to 10 minutes. If spontaneous improvement is not noted within 30 minutes, obtain radiographs to rule out a possible fracture. If findings on plain radiographs are negative for acute fracture and the child is still reluctant to use the arm, immobilize the arm in a sling and arrange orthopedic follow-up within 1 week for reassessment.

Macias CG, Bothner J, Wiebe R: A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics 102(1): 110, 1998.

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