Definition
Radial head subluxation
Mechanism
Average age 2 - 3 years
Axial traction with extended elbow
- annular ligament subluxes off radial head
- more common with ligament laxity
Examination
Pseudoparalysis
Tender over radial head
Limb in extension & pronation / pain on supination
X-Ray
Usually normal / exclude fracture
Mild increase radio-capitellar line > 3mm
Ultrasound
Increase radio-capitellar distance between elbows / > 3 mm difference suggestive of subluxation
Entrapped supinator muscle
Natural history
Subluxation
Usually self reduces
Long term radial head dislocation rarely reported
Recurrence
Can be recurrent with repeat injury
- associated with ligament laxity
- usually ceases after age of 5
Sevencan et al J Paediatr Orthop B
- 66 cases of pulled elbow
- higher success of closed reduction with immediate presentation
- all good outcomes
- recurrence 24%
Management
Closed reduction
Method
Analgesia
- supination + flexion or hyperpronation
- feel for snap
- immediate pain relief and arm use
Results
Bek et al Eur J Emerg Med 2009
- RCT of reduction method for 66 pulled elbows
- hyperpronation versus supination / flexion
- easier and more successful reduction with hyperpronation
Bexkens et al Am J Emerg Med 2017
- meta-analysis of 7 RCTs of closed reduction techniques in pulled elbow
- 700 patients, hyperpronation versus supination / flexion
- less pain and more successful reduction with hyperpronation
Failed closed reduction
Usually due to delayed presentation
- treat in sling
- will usually self reduce