Atlas of Primary Care Procedures, 1st Edition

Musculoskeletal Procedures

62

Reduction of Radial Head Subluxation (Nursemaid's Elbow)

Subluxation of the radial head (nursemaid's elbow) is a common childhood injury, which is seen most often between 6 months and 5 years of age. The radial head normally rotates against the ulna and capitellum (i.e., humerus), permitting forearm pronation and supination. The radial head is held in place against the proximal ulna and capitellum by ligaments and the joint capsule. Radial head subluxation usually is caused by the application of linear traction to a hand or wrist (i.e., longitudinal traction injury), such as by lifting a child by an outstretched hand. It may also be caused by an incidental fall in which the arm, elbow, and forearm are impacted between the ground and the child's trunk. Rarely, there is no known history of trauma, but the parents notice that the child is not using the affected limb.

Approach a child with suspected subluxation slowly and calmly to allay anxiety. The child is often best seated in the parent's lap. The affected arm is partially flexed at the elbow and in forearm pronation. Typically, the child keeps the arm close to the trunk and appears contented and playful but declines to actively move the affected arm. There is no tenderness to palpation of the clavicle, shoulder, humerus, elbow, forearm, wrist, or hand, and passive range of motion of the shoulder, hand, and wrist is usually painless. However, even modest attempts to supinate the forearm or to move the elbow elicit pain and anguish.

Radiographs are usually unnecessary, because there are no radiographic abnormalities associated with this condition and physical examination effectively diagnoses the problem. Radiographs should be considered if the child exhibits point tenderness, soft tissue swelling, or ecchymosis of the elbow.

After a reduction attempt, the child usually cries for a few seconds but then is easily comforted. Observe for 15 minutes for a full return to normal use. If function and use have not normalized within 15 minutes, a repeated attempt at reduction is recommended. Consider alternative diagnoses if the child's arm does not return to normal. Neurovascular compromise is rare with this injury. For children who recover full use after one or two reduction maneuvers, further therapy is unnecessary. A sling may be offered to the child whose function has improved but is not complete. Slings typically are useless in toddlers because they are easily discarded. Consider recommending that they wear a long-sleeved shirt and attach

P.504


the cuff buttonhole to an upper shirt button to help provide some immobilization.

Gently remind parents to avoid lifting the child by the hand, wrist, or forearm. Inform the parents that there is an increased risk of recurrence until the child reaches 5 to 6 years of age. Recurrent subluxation occurs in nearly one fourth of patients, and those 24 months or younger are at greatest risk.

INDICATIONS

  • Reduction of a subluxed radial head.

CONTRAINDICATIONS

  • Uncertainty about the diagnosis or possibility of occult fracture (i.e., further workup indicated)

P.505

 

PROCEDURE

Place the child's elbow in the fingers of your hand and your thumb over the child's radial head (i.e., lateral aspect of the proximal forearm). Grasp the child's affected hand with your other hand.

 

(1) Place the child's elbow in the fingers of your hand with your thumb over the child's radial head, and grasp the child's affected hand with your other hand.

Rapidly apply downward pressure on the radial head with your thumb, quickly followed by full supination and then full flexion of the child's elbow. A “click” is often palpated by the physician's thumb as reduction is accomplished.

 

(2) Rapidly apply downward pressure on the radial head with your thumb, quickly followed by full supination and then full flexion of the child's elbow.

P.506

 

CODING INFORMATION

CPT® Code

Description

2002 Average 50th Percentile Fee

24640*

Closed treatment of radial head subluxation in child (nursemaid's elbow) with manipulation

$193

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

No special equipment is needed for reduction of a radial head subluxation.

BIBLIOGRAPHY

David ML. Radial head subluxation. Am Fam Physician 1987;35:143–146.

Jongschaap HC, Youngson GG, Beattie TF. The epidemiology of radial head subluxation (“pulled elbow”) in the Aberdeen city area. Health Bull 1990;48:58–61.

McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med 1999;6:715–718.

Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child 1985;139:1194–1197.

Sacchetti A, Ramoska EE, Glascow C. Nonclassic history in children with radial head subluxations. J Emerg Med 1990;8:151–153.

Salter RB, Zaltz C. Anatomic investigations of the mechanism of injury and pathologic anatomy of “pulled elbow” in young children. Clin Orthop 1971;77:134.

Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med 1990;19:1019–1023.

Snyder HS. Radiographic changes with radial head subluxation in children. J Emerg Med 1990;8:265–269.

Teach SJ, Schutzman SA. Prospective study of recurrent radial head subluxation. Arch Pediatr Adolesc Med 1996;150:164–166.

Woo CC. Traumatic radial head subluxation in young children: a case report and literature review. J Manipulative Physiol Ther1987;10:191–200.