Overview
Also known as a nursemaid’s elbow or pulled elbow, radial head subluxation is a common upper limb injury in children <7 years old. It occurs because the attachment of the annular ligament covering the radial head is weaker in children than in adults, so it can be torn more easily.
As toddlers often hold the hand of a taller adult when walking, if they fall while held, this pulls on the elbow and can lead to subluxation. This pulling of the elbow is known as longitudinal traction, and this is a common mechanism of radial head subluxation.
Epidemiology
- Radial head subluxation is most common in children when they first start walking (around 1 year old) and when they fall more often (4 years old)
- Girls are more commonly affected than boys
Presentation
- The child stops using the arm and there is limited supination and elbow extension
- The child may hold the elbow slightly flexed and pronated with the forearm against the abdomen
- There is usually severe pain – the child usually refuses an examination due to this
Diagnosis
Overview
Pulled elbow is usually diagnosed clinically. An X-ray may be considered if a fracture is suspected or if reduction is unsuccessful after two or three attempts.
Management
Overview
If the diagnosis is clear and there is no suspicion of a fracture, the pulled elbow can be managed in primary care via reduction. Analgesia is given and the elbow joint is passively supinated while the elbow is held in flexion at 90 degrees.
After reduction, it may take around 30 minutes for normal function to return.
If reduction is unsuccessful after 2-3 attempts, then refer for an X-ray and further assessment.
Complications
- Reduction failure – this is rare
Prognosis
- Most cases are treated successfully with reduction and long-term complications are rare
