Pulled elbow

Pulled elbow
Other names: Radial head subluxation, annular ligament displacement,[1] nursemaid's elbow,[2] babysitter's elbow, subluxatio radii
Capsule of elbow-joint (distended). Anterior aspect. (Nursemaid's elbow involves the head of radius slipping out from the anular ligament of radius.)
SpecialtyEmergency medicine
SymptomsUnwilling to move the arm[2]
Usual onset1 to 4 years old[2]
CausesSudden pull on an extended arm[2]
Diagnostic methodBased on symptoms, Xrays[2]
Differential diagnosisElbow fracture[3]
TreatmentReduction (forearm into a palms down position with straightening at the elbow)[1][2]
PrognosisRecovery within minutes of reduction[1]
FrequencyCommon[2]

A pulled elbow, also known as a radial head subluxation,[4] is when the ligament that wraps around the radial head slips off.[1] Often a child will hold their arm against their body with the elbow slightly bent.[1] They will not move the arm as this results in pain.[2] Touching the arm, without moving the elbow, is usually not painful.[1]

A pulled elbow typically results from a sudden pull on an extended arm.[2] This may occur when lifting or swinging a child by the arms.[2] The underlying mechanism involves slippage of the annular ligament off of the head of the radius followed by the ligament getting stuck between the radius and humerus.[1] Diagnosis is often based on symptoms.[2] X-rays may be done to rule out other problems.[2]

Prevention is by avoiding potential causes.[2] Treatment is by reduction.[2] Moving the forearm into a palms down position with straightening at the elbow appears to be more effective than moving it into a palms up position followed by bending at the elbow.[1][4][5] Following a successful reduction the child should return to normal within a few minutes.[1] A pulled elbow is common.[2] It generally occurs in children between the ages of 1 and 4 years old, though it can happen up to 7 years old.[2]

Signs and symptoms

Symptoms and signs include:

  • The child stops using the arm, which is held in extension (or slightly bent) and palm down.[6]
  • Minimal swelling.[7]
  • Pain[7]
  • Varus deformity[7]

Cause

This injury has also been reported in babies younger than six months and in older children up to the preteen years. There is a slight predilection for this injury to occur in girls and in the left arm. The classic mechanism of injury is longitudinal traction on the arm with the wrist in pronation, as occurs when the child is lifted up by the wrist. [8][9]

If the forearm of a young child is pulled, it is possible for this traction to pull the radius into the annular ligament with enough force to cause it to be jammed therein. This causes significant pain, partial limitation of flexion/extension of the elbow and total loss of pronation/supination in the affected arm. [8][10]

Mechanism

The forearm contains two bones: the radius and the ulna. These bones are attached to each other both at the proximal, or elbow, end and also at the distal, or wrist, end. Among other movements, the forearm is capable of pronation and supination, which is to say rotation about the long axis of the forearm. In this movement the ulna, which is connected to the humerus by a simple hinge-joint, remains stationary, while the radius rotates, carrying the wrist and hand with it. To allow this rotation, the proximal (elbow) end of the radius is held in proximity to the ulna by a ligament known as the annular ligament. This is a circular ligamentous structure within which the radius is free, with constraints existing elsewhere in the forearm, to rotate.[11][12][13]

The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn. The older child will usually point to the dorsal aspect of the proximal forearm when asked where it hurts. This may mislead one to suspect a buckle fracture of the proximal radius.[14] There is no tear in the soft tissue (probably due to the pliability of young connective tissues).[14]

Diagnosis

Position of person and ultrasound. Elbows fully extended with the probe on the anterior portion of capitellar-radial joint.

Diagnosis is often based on symptoms.[2] X-rays may be done to rule out other problems.[2]

Differential diagnosis

The diagnosis of pulled elbow is done via exclision, below are some of the DDX: [15]

  • Septic elbow
  • Septic wrist
  • Supracondylar fracture
  • Radial head fracture



Treatment

To resolve the problem, the affected arm is moved in a way that causes the joint to move back into a normal position. The two main methods are hyperpronation and a combination of supination and flexion. Hyperpronation has a higher success rate and is less painful than a supination-flexion maneuver.[4][16]

References

  1. 1 2 3 4 5 6 7 8 9 Browner, EA (August 2013). "Nursemaid's Elbow (Annular Ligament Displacement)". Pediatrics in Review. 34 (8): 366–7, discussion 367. doi:10.1542/pir.34-8-366. PMID 23908364.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 "Nursemaid's Elbow". OrthoInfo - AAOS. February 2014. Archived from the original on 15 July 2018. Retrieved 4 December 2017.
  3. ↑ Cohen-Rosenblum, A; Bielski, RJ (1 June 2016). "Elbow Pain After a Fall: Nursemaid's Elbow or Fracture?". Pediatric Annals. 45 (6): e214–7. doi:10.3928/00904481-20160506-01. PMID 27294496.
  4. 1 2 3 Krul, M; van der Wouden, JC; Kruithof, EJ; van Suijlekom-Smit, LW; Koes, BW (28 July 2017). "Manipulative interventions for reducing pulled elbow in young children". The Cochrane Database of Systematic Reviews. 7: CD007759. doi:10.1002/14651858.CD007759.pub4. PMC 6483272. PMID 28753234.
  5. ↑ Bexkens, R; Washburn, FJ; Eygendaal, D; van den Bekerom, MP; Oh, LS (January 2017). "Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis". The American Journal of Emergency Medicine. 35 (1): 159–163. doi:10.1016/j.ajem.2016.10.059. PMID 27836316. S2CID 2315716.
  6. ↑ Radial Head Subluxation Joint Reduction at eMedicine
  7. 1 2 3 Blankenbaker, Donna G.; Davis, Kirkland W. (2016). Diagnostic Imaging: Musculoskeletal Trauma E-Book. Elsevier Health Sciences. p. 285. ISBN 978-0-323-44295-4. Archived from the original on 2021-08-29. Retrieved 2021-01-08.
  8. 1 2 Yamanaka, Syunsuke; Goldman, Ran D. (2018). "Pulled elbow in children". Canadian Family Physician. 64 (6): 439–441. ISSN 0008-350X. Archived from the original on 29 August 2021. Retrieved 19 January 2021.
  9. ↑ Rang, Mercer; Pring, Maya E.; Wenger, Dennis Ray (2005). Rang's Children's Fractures. Lippincott Williams & Wilkins. p. 121. ISBN 978-0-7817-5286-2. Archived from the original on 29 August 2021. Retrieved 19 January 2021.
  10. ↑ Nardi, Naomi M.; Schaefer, Timothy J. (2020). "Nursemaid Elbow". StatPearls. StatPearls Publishing. Archived from the original on 29 August 2021. Retrieved 19 January 2021.
  11. ↑ Sahrmann, Shirley (2010). Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines - E-Book. Elsevier Health Sciences. p. 298. ISBN 978-0-323-08378-2. Archived from the original on 29 August 2021. Retrieved 19 January 2021.
  12. ↑ Mitchell, Brittney; Whited, Lacey (2020). "Anatomy, Shoulder and Upper Limb, Forearm Muscles". StatPearls. StatPearls Publishing. Archived from the original on 27 February 2021. Retrieved 19 January 2021.
  13. ↑ Olson, Todd R.; Pawlina, Wojciech (2008). A.D.A.M. Student Atlas of Anatomy. Cambridge University Press. p. 288. ISBN 978-0-521-88756-4. Archived from the original on 29 August 2021. Retrieved 19 January 2021.
  14. 1 2 Nursemaid Elbow at eMedicine
  15. ↑ Rang, Mercer (2017). Rangs Children's Fractures. Lippincott Williams. p. 121. ISBN 978-0781752862. Archived from the original on 1 October 2021. Retrieved 1 October 2021.
  16. ↑ Bexkens, R; Washburn, FJ; Eygendaal, D; van den Bekerom, MP; Oh, LS (2 November 2016). "Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis". The American Journal of Emergency Medicine. 35 (1): 159–163. doi:10.1016/j.ajem.2016.10.059. PMID 27836316. S2CID 2315716.
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