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elbow subluxation; annular ligament displacement; radial-head subluxation; pulled elbow

Epidemiology: - common orthopedic injury in children - incidence of emergency department visits is 2.7 per 1000 in children <18 years of age.2 - median age at presentation is 2 years - injury is unique to infants & young children [1] Pathology: - the radial head is less bulbous than it is in older persons & may easily become displaced - during forceful longitudinal traction, such as when a child is pulled or lifted by the arm, the radial head is pulled underneath the annular ligament - the ligament then becomes entrapped proximal to the radial head at the level of the radiocapitellar joint Clinical manifestations: - pseudoparalysis: - child voluntarily keeps arm still to minimize discomfort - pain with movement, most often related to supination & pronation rather than to flexion & extension - in most cases there will be tenderness to palpation on the lateral side of the elbow - normal-looking elbow without effusion, bruising, or obvious deformity. Radiology: - radiographs almost always normal - positioning the elbow in preparation for radiography is often therapeutic in reducing the displacement Management: - reduction of subluxation is a safe outpatient procedure* - supination technique - with the child facing you, clasp both the hand & elbow of the affected arm - your fingers or thumb should overlie the radial head - supinate & flex the forearm until you feel the ligament move back into position - you may feel or hear a click as the ligament is reduced - if reduction is successful, the child should be pain free & able to move the arm normally in 5 to 30 minutes - hyperpronation technique - with the child facing you. clasp the hand of the affected arm as you would in a handshake - use your free hand to support the child's elbow - hyperpronate the child's wrist - you may feel or hear a click as the ligament is reduced - if reduction is successful, the child should be pain free & able to move the arm normally in 5 to 30 minutes [1] * ref [1] has a video illustrating reduction of elbow subluxation

Related

elbow (cubital joint)

General

subluxation

References

  1. Aylor M et al Reduction of Pulled Elbow N Engl J Med 2014; 371:e32. November 20, 2014 PMID: 25409393 http://www.nejm.org/doi/full/10.1056/NEJMvcm1211809