An adolescent female presents with acute right elbow pain after a fall during a soccer match. She landed on her hand with the elbow hyperextended. She had full, pain-free range of motion of the shoulder and wrist. She had mildly reduced range and mild tenderness diffusely around the entire elbow. She was given ice, placed in a sling for comfort, and advised to follow up the next day with sports medicine. On follow up, she reported continued pain and difficulty moving her elbow fully, but was still able to perform most routine activities at home. Repeat exam in clinic revealed worsening restrictions in elbow range of motion compared to immediately post-injury as below. And she was sent to the pediatric emergency room.

ED Evalaution

After presentation to the ED, xrays were ordered ...

The patient was observed returning from the x-ray suite with a normal arm swing while walking.

She reports that when the x-ray technologist positioned her arm straight for one of the views, her elbow suddenly felt a lot better.

Repeat exam now showed full ROM with only mild pain at end ranges, and minimal tenderness over the lateral elbow!

RESULT:

The osseous structures are in normal anatomic alignment without fracture, subluxation, or dislocation. Osseous mineralization is normal. The articular surfaces are intact without focal defect. No elbow joint effusion. The surrounding soft tissues are unremarkable without radiopaque foreign body.

IMPRESSION:No acute left elbow abnormality.

Discussion

Radial head subluxation occurs when the radial head slips under the annular ligament. Subluxation or nursemaid’s elbow is common in younger children. The classic mechanism is a tractional force being applied to an extended, pronated arm. This injury becomes unusual after 7 years of age as the annular ligament strengthens. Complete radial head dislocation is generally due to high force injury, and is highly associated with Monteggia fractures or elbow dislocation.

Isolated radial head subluxations or dislocations are rare and may be missed on x-rays, leading to delayed diagnosis.

Treatment for both is with closed reduction, using traction and hyperpronation. Dislocations may require surgery