CME REVIEW ARTICLE Current Approach to the Management of Forearm and Elbow Dislocations in Children Michael Gottlieb, MD, RDMS and Linda I. Suleiman, MD RADIAL HEAD SUBLUXATIONS Abstract: Pediatric orthopedic injuries are a common reason for presen- tation to the emergency department. This article sequentially discusses 2 important upper extremity injuries that require prompt management in Background the emergency department. Radial head subluxations are discussed with a Radial head subluxation, also referred to as “nursemaid's el- focus on current evidence for imaging, reduction techniques, and follow- bow” or “pulled elbow” is the most common orthopedic injury 1 up. Elbow dislocations, although less common than radial head subluxa- among children under the age of 6 years. One study demonstrated tions, are also addressed, highlighting imaging, reduction, immobilization, an overall incidence of 1.2% per year among children aged 0 to 2 and follow-up recommendations. 5 years. In the United States, the incidence of emergency care visits for radial head subluxation has been reported to be 2.7 to 5.0 per Key Words: forearm, elbow, dislocation, reduction, nursemaid's, 1000 children aged 0 to 18 years.3,4 pulled elbow It occurs most commonly in toddlers with a peak incidence – (Pediatr Emer Care 2019;35: 293–300) between 2 to 3 years of age.4 12 However, it can occur in patients as young as 22 days and as old as 16 years.10,13 Studies suggest that it is significantly more common in girls than boys.4–12,14 TARGET AUDIENCE This CME activity is intended for practitioners who care for pediatric patients presenting with forearm or elbow dislocations, Anatomy and Pathophysiology which may include general pediatricians, pediatric emergency Although multiple theories have been proposed to explain physicians, general emergency physicians, orthopedic surgeons, this injury, the current evidence supports a partial annular liga- and sports medicine specialists. ment tear or momentary distraction of the radiocapitellar joint that occurs in pronation, allowing the annular ligament to slip under the radial head, becoming entrapped in the joint space.5,15–18 Be- LEARNING OBJECTIVES cause the anterior portion of the radial head is narrower and forms After completion of this CME article, readers should be better a more acute angle when compared with the posterior or lateral as- able to: pects, dislocation is more common in pronation.5,16,17 By the age of 5 years, the annular ligament is much thicker and stronger, 1. Describe the historical and physical examination findings thereby reducing the likelihood that it will tear or be displaced.16 suggestive of radial head subluxation and elbow dislocation. The most common mechanism for the injury is an axial 2. Differentiate reduction techniques for radial head subluxation pulling force applied to a child's arm in extension with the forearm and elbow dislocation. pronated.5,6,17,19 The left arm is affected more commonly than the – 3. Explain the disposition and follow up recommendations for right.6 8,11,12,14,20 This may be owing to the larger number of patients after reduction of a radial head subluxation and right-handed than left-handed caregivers or increased muscle elbow dislocation. strength in the patient's dominant arm. ediatric orthopedic injuries are a common presentation to History and Physical Examination P emergency departments. Among these injuries, radial head Classically, the caregiver will report that the child refused to subluxation and elbow dislocation are 2 important upper extremity move his or her arm after the caregiver pulled on the child's dislocations. It is essential for providers to understand the diagnos- arm.5,6,11 The most common reasons the child's arm is pulled tic strategies, reduction techniques, and postreduction management are to prevent the child from falling, picking the child up after a for these common conditions. Each injury is discussed sequentially fall, pulling the arm through a tight sleeve, or swinging the child in the following sections. by the arms.5,11,20 Interestingly, up to 25% of cases are associated with a fall or direct trauma to the elbow.9–11 Children typically en- dorse elbow pain but may experience referred pain to the wrist Assistant Professor and Director of Ultrasound (Gottlieb), Department of 5,6 Emergency Medicine, Rush University Medical Center, Chicago, IL; Assistant or shoulder. Professor (Suleiman), Department of Orthopedic Surgery, Rush University Med- The affected arm is held against the body with the elbow in ical Center, Chicago, IL. slight flexion and the forearm pronated. There is usually no swell- The authors, faculty, and staff in a position to control the content of this CME ing, deformity, or point tenderness of the elbow or distal humerus. activity and their spouses/life partners (if any) have disclosed that they have 16 no financial relationships with, or financial interest in, any commercial There may be slight tenderness to palpation of the radial head. organizations relevant to this educational activity. Pain is elicited with passive pronation and supination, although Reprints: Michael Gottlieb, MD, RDMS, Department of Emergency Medicine, flexion and extension are usually painless.16,21 However, patients Rush University Medical Center, 1750 West Harrison St, Suite 108 Kellogg, Chicago, IL 60612 (e‐mail: [email protected]). may still become upset with these movements owing to the asso- Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. ciated anxiety. Although a classic history and examination support ISSN: 0749-5161 the diagnosis of radial head subluxation, the provider should Pediatric Emergency Care • Volume 35, Number 4, April 2019 www.pec-online.com 293 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Gottlieb and Suleiman Pediatric Emergency Care • Volume 35, Number 4, April 2019 FIGURE 1. Supination (left) followed by flexion (right) technique for forearm reduction. examine and palpate the entire arm and clavicle to avoid missing Although the child may be hesitant to move the arm, movement can an alternate or concomitant injury. be elicited by offering a toy or sticker and having the child reach with the affected arm. Postreduction radiographs are not indicated unless Imaging the child continues to not move the arm or there is concern for iatrogenic injury. Radial head subluxation is a clinical diagnosis, and radio- graphs are rarely necessary. However, radiographs should be ob- tained when there is an obvious effusion, ecchymosis, tenderness Complications to palpation, or a significant mechanism of injury. Radiographs Neurologic or vascular damage are exceedingly rare with this should also be considered if the child does not resume moving injury. The most common complication is a predisposition to re- the arm after the reduction. Radiographs often appear normal in ra- current radial head dislocations, with recurrence rates ranging dial head subluxations.5 However, studies have suggested that fail- from 23% to 39%.5–9 Risk of recurrence is more common in pa- ure of a line extending in the longitudinal direction from the radius tients who present under the age of 2 years.5,7–9 However, studies to bisect the capitellum (ie, radiocapitellar line) may suggest radial have not demonstrated a significant difference in recurrence rates head subluxation.22,23 Commonly, the forearm will undergo inci- based upon duration of follow up interval, sex, laterality, or family dental reduction while obtaining the radiographs.11,16 history of radial head subluxation.6,8 Although not commonly used, ultrasound may facilitate the diagnosis of this condition. A linear probe is used to evaluate Disposition the location of the radial head and surrounding structures. Findings Neither splinting nor orthopedic referral is required after a include a widened space between the radial head and capitellum, in- successful reduction. If reduction fails after both techniques, place creased joint space echogenicity, visualization of the supinator mus- the patient in a posterior long arm splint and have the patient fol- cle entering the joint space (ie, the “hook sign”), displacement of – low up with an orthopedic surgeon in 1 to 2 days. the annular ligament, and enlargement of the synovial fringe.24 29 It is also important to educate parents to avoid traction on the forearm and elbow to avoid recurrence of the subluxation. One Management case series even described successful reduction of recurrent sub- There are 2 primary techniques for reducing radial head sub- luxations by parents while receiving instructions over the phone luxations. Although both techniques were discovered in the same by a trained medical provider.40 year, supination-flexion has been the predominant technique em- Recurrent subluxations may benefit from immobilization phasized for over a century.21,30–32 However, more recent data after the reduction in a posterior long arm splint with the elbow have challenged this reduction strategy.9,20,33–39 Both techniques are described hereafter, as it is the authors' opinion that either tech- nique should serve as a secondary reduction strategy if the first at- tempt is unsuccessful. The supination-flexion technique involves supinating the patient's affected forearm and flexing the arm at the elbow in one fluid motion (Fig. 1). The second approach, referred to as the hyperpronation technique, involves extending the arm at the elbow and fully pronating the arm (Fig. 2). A variant of this tech- nique