Ver el código de «Radial head subluxation»

==Background==
[[File:Gray331.png|thumb|Anterior capsule of elbow-joint. Nursemaid's elbow involves the head of radius slipping out from the anular ligament of radius.]]
[[File:Elbow subluxation.png|thumb|Medical illustration showing the displaced angular ligament with elbow subluxation.]]
[[File:Elbow subluxation mechanisms.png|thumb|Common radial head subluxation mechanisms of injury.]]
*Also known as "Nursemaid's elbow" an "pulled elbow"
*Radial head subluxation due to longitudinal traction on arm
**Annular ligament of radius displaces into radiocapitellar articulation
*Age 1y-5y (peak 2y-3y)
**After this point, the change in shape of the radial head with growth protects against subluxation

==Clinical Features==
===History===
*Typical history includes sudden longitudinal traction on the arm
**Swinging child by arms by playing
**Pulling child back from walking into traffic
**Catching child who is falling
*Younger children may sustain the injury by less classic mechanisms
*Sudden onset of pain

===Physical===
*Refusal to use the affected arm
*Arm held in extension
*Refusal to supinate
*''Non''-tender to palpation
*Limited edema
*No bruising

==Differential Diagnosis==
{{Elbow DDX}}

==Evaluation==
*Clinical diagnosis
**Patients with classic story (toddler 1-3 years old, low energy mechanism) and findings (no bruising/swelling, no point tenderness, arm held adducted/pronated) do not require imaging before reduction<ref>Genadry KC, Monuteaux MC, Neuman MI, Lipsett SC. Management and Outcomes of Children With Nursemaid's Elbow. Ann Emerg Med. 2021 Feb;77(2):154-162. doi: 10.1016/j.annemergmed.2020.09.002. Epub 2020 Oct 27. PMID: 33127100.</ref>
**Any child with an unclear story or unsuccessful reduction should undergo imaging to rule other pathology
*Assess neurovascular status prior to (and following) reduction

==Management==
[[File:Fixing nursemaid elbow hariadhi.png|thumb|Hyperpronation (A) and supination (B) techniques. These techniques may also be combined in practice.]]
===Reduction===
''Hyperpronation has greater first attempt success (94% vs 69%), but both have similar overall reduction rate;<ref>Pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial. Eur J Emerg Med. 2009 Jun;16(3):135-8. doi: 10.1097/MEJ.0b013e32831d796a.</ref> consider doing both techniques at once in quick succession''
*Hyperpronation Technique
**Hold patient's elbow at 90 degrees with one hand
***Place thumb over radial head to facilitate reduction and provide tactile feedback
**With other hand hyperpronate patient's wrist
*Supination Technique
**Hold patient's elbow at 90 degrees with one hand
***Place thumb over radial head to facilitate reduction and provide tactile feedback
**With other hand supinate patient's wrist and fully flex elbow

===Post-Reduction===
*If successful, patient will have return of full range of motion within 30min
**Usually child with begin to spontaneously use the affected arm
**If child is not using affected arm, may try offering a popsicle or toy and encouraging to reach with affected arm
*If unsuccessful after multiple attempts, obtain x-ray and consider alternative diagnoses (e.g. [[Salter-Harris fracture]])

==Disposition==
*Discharge home after successful reduction
*No immobilization
*Caution caregivers to avoid longitudinal traction on arm
*Advise caregivers that injury is frequently recurrent until radial head maturity

==See Also==
*[[Elbow diagnoses]]

==External Links==
*[https://www.merckmanuals.com/professional/injuries-poisoning/how-to-reduce-dislocations-and-subluxations/how-to-reduce-a-radial-head-subluxation-nursemaids-elbow?query=nursemaid%20elbow| Merk Manual: How To Reduce a Radial Head Subluxation (Nursemaid's Elbow)]

==References==
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[[Category:Pediatrics]]
[[Category:Orthopedics]]