Recurrent nursemaid's elbow (annular ligament displacement) treatment via telephone.

Kaplan RE, Lillis KA.

Department of Pediatrics, Division of Ambulatory, SUNY at Buffalo School of Medicine and Biomedical, Sciences, Children's Hospital of Buffalo, Buffalo, New York 14209, USA.

Annular ligament displacement (ALD)--also termed radial head subluxation, nursemaid's elbow, or pulled elbow--can be successfully diagnosed and treated over the telephone by properly trained medical professionals instructing nonmedical caretakers. Two case reports of successful ALD reduction via telephone are described. The pathology of ALD and techniques for its treatment are reviewed, and guidelines are given. The rationale for the introduction of the new term annular ligament displacement as well as areas for additional investigation are discussed. To our knowledge, this is the first published account of ALD reduction via telephone.

J Manipulative Physiol Ther. 1987 Aug;10(4):191-200. <
Traumatic radial head subluxation in young children: a case report and literature review.

Woo CC.

Traumatic radial head subluxation in young children is reviewed. This minor condition commonly results from a sudden longitudinal traumatic pull on pronated and extended forearm and appears to be infrequently recognized or diagnosed. Differential diagnosis of traumatic radial head subluxation from traumatic radial head dislocation, congenital radial head dislocation, brachial plexus palsy and "invisible" elbow fractures are discussed. It is postulated here that there are two types of traumatic rotary radial head subluxation in pronation, the simple type and the lateral type. Careful analysis of anteroposterior view of elbow reveals the change of the shape and position of the radial tuberosity indicating the simple type, or concommitant with lateral displacement of the radial head on the ulna indicating the lateral type. The lateral type and its reposition are demonstrated when premanipulative roentgenograms are compared with postmanipulative roentgenograms in one of the eight illustrative cases. Details of the supination manipulative reduction are described and demonstrated.

 Pediatrics. 1998 Jul;102(1):e10.
A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations.

Macias CG, Bothner J, Wiebe R.

Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA.

OBJECTIVE: To compare supination at the wrist followed by flexion at the elbow (the traditional reduction technique) to hyperpronation at the wrist in the reduction of radial head subluxations (nursemaid's elbow). MATERIALS AND METHODS: This prospective, randomized study involved a consecutive sampling of children younger than 6 years of age who presented to one of two urban pediatric emergency departments and two suburban pediatric ambulatory care centers with a clinical diagnosis of radial head subluxation. Patients were randomized to undergo reduction by one of the two methods and were followed every 5 minutes for return of elbow function. The initial procedure was repeated if baseline functioning did not return 15 minutes after the initial reduction attempt. Failure of that technique 30 minutes after the initial reduction attempt resulted in a cross-over to the alternate method of reduction. The alternate procedure was repeated if baseline functioning did not return 15 minutes after the alternate procedure was attempted. If the patient failed both techniques, radiography of the elbow was performed. RESULTS: A total of 90 patients were enrolled in the study. Five patients were removed from further analysis secondary to a final diagnosis of fracture, 84 were reduced successfully, and 1 failed both techniques. Demographic characteristics of each group were similar. Thirty-nine of 41 patients (95%) randomized to hyper-pronation were reduced successfully on the first attempt versus 34 of 44 patients (77%) randomized to supination. Two patients in the hyperpronation group required two attempts versus 10 patients in the supination group. Hyperpronation was more successful; 40 of 41 patients (97.5%) in the hyperpronation group were reduced successfully versus 38 of 44 patients (86%) in the supination group. Of the 6 patients who crossed over from supination to hyperpronation, 5 were reduced on the first attempt and 1 was reduced on the second attempt. CONCLUSIONS: In the reduction of radial head subluxations, the hyperpronation technique required fewer attempts at reduction compared with supination, was successful more often than supination, and was often successful when supination failed.

Am Fam Physician. 1987 Apr;35(4):143-6.
Radial head subluxation.

David ML.

Radial head subluxation occurs when the thin, weakly attached annular ligament of the forearm becomes entrapped in the radiocapitellar space after marked traction on the extended, pronated arm. It is the most common musculoskeletal injury in children between two and five years of age. Awareness of this condition permits easy diagnosis and rapid treatment by simple manipulation.

Br J Radiol. 1994 Dec;67(804):1176-85.
Pulled elbow in childhood.

Bretland PM.

Watford General Hospital, Herts, UK.

In this injury, a sudden pull on the pronated, extended arm of a child up to 5 years of age is followed by refusal to use the arm. After a simple flexion, supination and extension manoeuvre the child starts using the arm in minutes. Radiographs are said to be normal. At least 13 theories of the mechanism have been advanced. Anterior subluxation of the radial head has never been proved radiographically or experimentally. Available evidence favours momentary distraction of the radiocapitellar joint in pronation which allows upward slip of the annular ligament upon the radial head at its shortest diameter and interposition of part of the anterior capsule between the two bones. Radiography is difficult, usually producing oblique views in pronation which are not easy to interpret. The main differential diagnosis is from epiphyseal rotation. In any doubtful case early repeat radiography is essential taking matched views of both elbows, even if non-standard. A collection of 28 radiographs has been analysed, two recent typical contrasting cases are presented, two signs to identify an oblique view of a normal elbow are described and the literature is reviewed. If the best radiograph available in an injured elbow in a child is a normal oblique view in pronation, pulled elbow is a likely diagnosis.

J Pediatr Orthop. 1995 Jul-Aug;15(4):454-6. Acute annular ligament interposition into the radiocapitellar joint in children (nursemaid's elbow).

Choung W, Heinrich SD.

Department of Orthopaedics, Louisiana State University Medical School, New Orleans, USA.

Acute annular ligament interposition into the radiocapitellar joint ("nursemaid's elbow") is a common injury in children younger than 5 years. The injury occurs when axial traction is applied to an extended, pronated arm. There are no abnormal radiographic findings associated with this condition. We recommend that children with a classic history and clinical presentation of an acute annular ligament interposition into the radiocapitellar joint be treated without obtaining radiographs.


Nonclassic history in children with radial head subluxations.

Sacchetti A, Ramoska EE, Glascow C.

Our Lady of Lourdes Medical Center, Camden, New Jersey.

Radial head subluxation (RHS) is a common pediatric orthopedic injury, frequently diagnosed through the classic history of axial traction to the upper extremity of a child. However, not all children with RHS will present with this classic history. This may result in misdiagnosis and delay of appropriate treatment. To evaluate the prevalence of non-classic presentations, a retrospective study was conducted of 45 emergency department patients with RHS. Of these patients, 15 presented with an atypical history. All patients were in minimal distress, holding their affected arms semiflexed and pronated (the nursemaid's position). The classic and nonclassic history groups were equivalent in patient age, spontaneous reductions, and physician reductions. A trend towards more radiographs was noted in the nonclassic group. This study suggests that even in the absence of the classic history of upper extremity traction, radial head subluxation should be suspected in any pediatric patient with an upper extremity complaint who presents with the affected arm in the nursemaid's position.

Orthop Nurs. 2000 Jul-Aug;19(4):49-52; quiz 53-5
Did you check your nursemaid's elbow?

Kunkler CE.

Tioga Nursing Facility, Guthrie Healthcare System, Waverly, New York, USA.

Imagine a parent innocently swinging around a toddler ... a yank on an outstretched arm to keep a preschooler from falling ... a caregiver attempting to move a reluctant child by dragging the child by the hand ... a helping hand to lift a young child up over the curb or a high step. None of these activities is ever intended to hurt a child, yet the result of these specific activities send many children with anxious parents and caregivers to emergency departments and unscheduled pediatrician appointments each year. Nursemaid's elbow, also known as a pulled elbow or a subluxated radial head, may result from the specific activities described above and is the most common dislocation injury handled by pediatricians. Most commonly occurring in the 1-year to 4-year old age group, nursemaid's elbow is easily treated and generally has no long-term sequelae.


Am J Dis Child. 1985 Dec;139(12):1194-7.
The epidemiology and treatment of radial head subluxation.

Quan L, Marcuse EK.

The incidence and treatment of radial head subluxation were evaluated in emergency room and private office settings. Factors associated with recurrence and with successful reduction were identified, and ways to prevent this common injury were sought. Of 54 reductions during which a click was either felt or heard, all but one reduction resulted in reuse of the arm within 30 minutes. Of 13 reductions in which a click was neither felt nor heard, only four reductions resulted in reuse of the arm within 30 minutes. A supination maneuver resulted in reuse of the arm within 30 minutes in all 27 patients seen two or more hours after injury vs 85% (34/40) of patients seen less than two hours after injury. Remanipulation 12 to 106 hours later resulted in reuse of the arm in all those children who had failed to respond to previous treatment.

Arch Orthop Trauma Surg. 2000;120(5-6):336-7. 
The treatment of pulled elbow: a prospective randomized study.

Taha AM.

Department of Surgery, American University of Beirut Medical Center, Lebanon.

To evaluate the effectiveness in decreasing recurrence of cast application after manual reduction of pulled elbow. Sixty-four children with pulled elbow were randomized into two treatment groups: Group A underwent manipulative reduction followed by splinting the elbow in a flexed and supinated position for 2 days; group B underwent manipulative reduction only. Both groups were examined 2, 5, and 10 days later. None of the 33 patients in group A had a pulled elbow at follow-up. Four (13%) of 31 patients in group B had a pulled elbow 2-5 days later. Immobilizing the elbow for 2 days after manipulative reduction improves the success of treatment of a pulled elbow.

 J Bone Joint Surg Br. 1977 Nov;59-B(4):402-7.
Anterior dislocation of the radial head in children: aetiology, natural history and management.

Lloyd-Roberts GC, Bucknill TM.

The results of operation for traumatic anterior dislocation of the head of the radius in eight children have been reviewed. We are satisfied on the basis of the results obtained and the outcome in one untreated patient that operative reduction is fully justified, provided that the annular ligament is reconstructed and internal fixation employed. We have not seen unilateral congenital dislocation and doubt its existence. Secondary subluxation of the distal radio-ulnar joint has been noted in an untreated patient.