Radial Head Subluxation

Radial head subluxation, commonly known as “nursemaid’s elbow,” is a partial dislocation of the radial head from its normal position at the elbow joint. It typically occurs in young children, particularly those under the age of five, and is considered one of the most common elbow injuries in this age group (1). The condition arises when the annular ligament, which holds the radial head in place, slips over the bone, allowing the radial head to move out of its normal alignment. Though distressing for both child and caregiver, radial head subluxation is generally benign and can be easily corrected with prompt treatment (1).

Symptoms

Radial head subluxation usually presents with immediate signs following the inciting event, which is often a pulling or yanking motion on the arm. Common symptoms include (2):

• Sudden onset of pain in the affected elbow or forearm.
• Reluctance or refusal to use the arm; the child may let the arm hang limply at their side.
• Lack of swelling or visible deformity, which differentiates it from fractures.
• The affected arm is typically held slightly bent at the elbow and pronated (palm facing down).
• Crying or irritability, especially when attempting to move the arm.

Importantly, children with radial head subluxation often appear fine until they try to use the arm, at which point the pain becomes apparent (2).

Causes

Radial head subluxation is primarily caused by a sudden traction force on the extended and pronated arm. The mechanism involves the annular ligament slipping off the radial head and becoming trapped, leading to the subluxation (1) . Common scenarios include:

• Pulling a child up by the hands or forearms (e.g., lifting them over a curb).
• Swinging a child by the arms.
• Jerking the arm while trying to prevent a fall.
• Sudden yanking when a child resists holding hands or being led.

In rare cases, minor trauma or rolling over in bed may also lead to this injury, especially in children with looser ligaments (1).

Risk Factors

While radial head subluxation can potentially occur in any young child, certain factors increase the likelihood (2):

• Age: Children between 1 and 4 years old are most susceptible due to the immature structure of the elbow joint and laxity of the ligaments.
• Gender: Some studies suggest it may be more common in girls than boys.
• History of previous injury: Children who have experienced one episode are at greater risk for recurrence.
• Ligament laxity: Congenital conditions that affect connective tissue may predispose to joint instability.
• Parental handling: Inadvertent rough handling during play or discipline can increase the risk.

Diagnosis

Radial head subluxation is typically diagnosed clinically based on a clear history and physical examination. Imaging is usually unnecessary but may be considered in atypical cases (3).

• History: Parents often report a pulling injury or that the child was lifted or swung by the arm.
• Physical exam: The child holds the arm close to the body with minimal movement. Tenderness is usually localized to the radial head.
• X-rays: May be used to rule out fractures if the history is unclear, or if the child does not begin using the arm shortly after attempted reduction.

Due to the subtle nature of the injury, careful clinical judgment is crucial in distinguishing subluxation from fractures or soft tissue injuries.

Treatment Options

Treatment for radial head subluxation involves a simple manual reduction maneuver performed by a healthcare professional (3). Two primary methods are commonly used:

Supination-Flexion Technique:

• The child’s arm is gently supinated (palm turned upward) and then flexed at the elbow.
• A “click” or “pop” may be felt or heard, indicating the ligament has returned to its proper position.

Hyperpronation Technique:

• The forearm is pronated (turned downward) while the elbow is supported and slightly flexed.
• This method is often more successful on the first attempt and may be less painful.

Following successful reduction, the child usually begins using the arm normally within minutes. No splinting or medication is typically required unless there is recurrence or another injury is suspected (1).

If reduction is unsuccessful after several attempts, or if the diagnosis is uncertain, further evaluation with imaging and orthopedic consultation may be needed (2).

Living With or Prevention

Radial head subluxation is not usually associated with long-term complications, especially if treated promptly. However, recurrence is possible. Preventive strategies include:

• Educating caregivers: Avoid lifting children by their arms or wrists; instead, lift under the armpits.
• Safe play practices: Discourage swinging children by their hands or arms.
• Supervision: Young children should be supervised closely, especially in environments where they may resist being led or pulled.
• Recurrent cases: If a child experiences multiple episodes, a referral to a pediatric orthopedic specialist may be necessary. In rare cases of frequent recurrence, surgical intervention might be considered to tighten the annular ligament.

References

1. Piroth P, Gharib M. Die traumatische Subluxation des Radiusköpfchens (Chassaignac) [Traumatic subluxation of the head of the radius (author’s transl)]. Dtsch Med Wochenschr. 1976 Oct 15;101(42):1520-3. German. doi: 10.1055/s-0028-1104365. PMID: 976117.
2. Li SG, Lv SJ, Zhang DY, He BJ. Conservative treatment of congenital radial head subluxation and non-traumatic elbow locking: A case report. Jt Dis Relat Surg. 2024 Mar 21;35(2):410-416. doi: 10.52312/jdrs.2024.1608. Epub 2024 Mar 21. PMID: 38727122; PMCID: PMC11128957.
3. Rozzi SL, Anderson JM, Doberstein ST, Godek JJ, Hartsock LA, McFarland EG. National Athletic Trainers’ Association Position Statement: Immediate Management of Appendicular Joint Dislocations. J Athl Train. 2018 Dec;53(12):1117-1128. doi: 10.4085/1062-6050-97-12. Epub 2019 Jan 4. PMID: 30609383; PMCID: PMC6365071.