What is Nursemaid Elbow (Radial Head Subluxation)?
Nursemaid’s elbow, also known as “radial head subluxation,” is a common injury in young children where a part of the elbow called the radial head slips under a band of fibrous tissue known as the annular ligament. This causes pain and makes it difficult for the child to rotate their forearm. Usually, doctors can identify this injury through a physical examination and by asking about the child’s medical history. Most of the time, the doctor can correct the problem right in their office or clinic.
What Causes Nursemaid Elbow (Radial Head Subluxation)?
The annular ligament is a band of tissue that wraps around the top part of the radius bone in your arm, keeping it attached to the ulna bone. The radius is one of the two long bones in your forearm, while the ulna is the other one.
If you pull your arm while it is turned inwards and straightened, the annular ligament could slip off the top of the radius. Once this happens, it could get stuck in the joint between the radius and a part of the elbow called the capitellum.
Risk Factors and Frequency for Nursemaid Elbow (Radial Head Subluxation)
Radial head subluxation, also known as RHS, often occurs in children between the ages of 1 and 4. In fact, it accounts for over 20% of all upper limb injuries in children. As children grow older, particularly past the age of 5, this condition becomes less common because the annular ligament in the elbow gets stronger with age. Girls tend to experience this more frequently than boys, and it’s usually the left arm that’s affected more than the right. There’s also a chance of it happening again, with a recurrence rate around 20%.
Signs and Symptoms of Nursemaid Elbow (Radial Head Subluxation)
Radial head subluxation, also known as “pulled elbow” or “nursemaid’s elbow”, is a common injury in children. Sometimes, caregivers may describe an incident of child’s arm being pulled upward by the wrist or the child being swung around by the arms just before the symptoms started. However, sometimes no specific trauma is remembered. Symptoms can also happen after a fall on an outstretched arm.
When these children are examined, they may appear nervous and hold the injured arm in a protective way. This arm might often be fully or almost fully straightened and turned palm down. The child might refuse to move the arm and become upset when it is touched but is generally not in pain unless the arm is moved. They might resist if a healthcare provider tries to turn the arm, bend it or straighten it. Usually, there will not be any bruising, redness, swelling, or other signs of a trauma. While the child might not cooperate, it can be checked that they have feeling and muscle movement in the part of the arm below the elbow.
Sometimes, the pulled elbow might get back in place on its own before the child sees a doctor. This might confuse and worry the parents, especially when the child refuses to move the arm and seems very upset by any attempt to manipulate or touch the arm, but then all the symptoms suddenly disappear. In this case, after confirming nothing else seems wrong, the doctor reassures the parents that this happened because of the pulled elbow, and everything is fine now.
Testing for Nursemaid Elbow (Radial Head Subluxation)
If you’ve hurt your arm, your doctor will need to do a thorough check of that entire arm, along with your clavicle on the same side. This will involve feeling along your bones and joints to see if they’re tender. They’ll be trying to see if the upper part of your radius bone, near your elbow, has slipped out of place. This is called radial head subluxation.
The doctor can usually tell if you have radial head subluxation just by examining you. However, if they think you might have broken a bone, dislocated your elbow, or if your arm is swollen or looks deformed, they might decide to do some imaging tests. Similarly, if the injury didn’t happen through your arm being pulled on, or if they suspect the injury wasn’t accidental, then they’ll also want to do an imaging test.
The kind of imaging test they’ll use is called a radiograph. It’s basically like an X-ray. In cases of radial head subluxation, these X-ray pictures usually look normal. Sometimes, though, they might show that the line between the radius and an elbow bone called the capitellum is misaligned.
Treatment Options for Nursemaid Elbow (Radial Head Subluxation)
The treatment usually involves a quick, non-surgical procedure called ‘closed reduction.’ This procedure aims to place the dislocated part of the elbow (annular ligament) back into its correct position. Even though this process is brief, it may cause momentary discomfort. However, the pain typically resolves immediately after the procedure, and within a few minutes, the child can resume their normal activities.
During the procedure, to keep the child at ease, the caregiver should hold the child while the examiner performs the procedure.
The closed reduction is usually performed using two techniques – ‘hyperpronation’ and ‘supination/flexion.’ Studies suggest that hyperpronation tends to be more successful and possibly less painful at the first attempt than the latter technique. If the hyperpronation method doesn’t work, then the supination/flexion technique is tried.
In the hyperpronation method, the examiner applies moderate pressure to the dislocated part of the elbow (radial head) while supporting the child’s elbow. The forearm is then turned inwards forcefully. If the repositioning is successful, the examiner may feel a click.
For the supination/flexion technique, the examiner applies slight pressure to the radial head using their thumb while supporting the elbow. They then rotate the forearm and bend it upwards, applying gentle traction. If it’s successful, there might be a click sound or feeling.
The test for successful reduction is an immediate relief from pain and regained arm function. Most children will start using their arm within 5 to 10 minutes. Yet, sometimes, it can take a few extra minutes for children to realize it no longer hurts to move the arm. If the child still cannot move their arm, medical imaging might be necessary to check for fractures. If there are no fractures, but the child still refuses to use their arm, they may need to wear a sling and possibly see an orthopedic surgeon.
If reduction is successful, no more treatments such as a splint or sling are needed after the procedure. The prognosis is excellent in such cases. However, to prevent the accident from occurring again, parents should be instructed to avoid activities that exert straight-line force on the arm, such as lifting the child or swinging them by the hands, wrists, or forearms.
What else can Nursemaid Elbow (Radial Head Subluxation) be?
These are different types of injuries that can occur in the arm:
- Elbow fracture
- Fractured wrist
- Green stick fracture
- Hand injury
- Monteggia fracture
- Supracondylar fracture
- Soft tissue damage of hand
