The peak incidence of radial head subluxation (nursemaids’ elbow) occurs
in children 2 to 3 years of age, with a range from 6 months to 7
years. Girls are seen with the injury more commonly than boys. Left-sided
injury is more common, presumably because most caretakers are right-handed.
The usual mechanism of injury is sudden longitudinal traction on
the arm with the elbow extended, such as occurs when a child is pulled
up by the arm, although up to half of injuries are associated with other
In radial head subluxation the annular ligament of the radius
displaces into the radiocapitellar articulation. The child will
not move the affected arm, but is otherwise not in any distress.
The arm is held in an adducted, semiflexed, and prone position.
On palpation there is no significant point tenderness or swelling.
There may be some discomfort on palpation of the radial head on
the affected side. Attempts at pronation and supination of the forearm
are painful. Radiographs are not necessary if the clinical suspicion
of radial head subluxation is high. There are two maneuvers for
reduction, the supination technique and the hyperpronation technique.
To perform the supination technique (Figure 143C-1) hold the child’s elbow at 90 degrees with
one hand, then firmly supinate the
child’s wrist, and then flex the child’s elbow
so that the wrist is directed to the same (ipsilateral) shoulder.
Supination technique. Hold the elbow at 90 degrees, then
firmly supinate the wrist and the forearm toward the ipsilateral shoulder.
The hyperpronation technique1 (Figure 143C-2) is reported to be more successful and may be less painful.
The technique may be used primarily or as a backup technique when
supination fails. Hold the child’s elbow at 90 degrees
in one hand, then firmly pronate the child’s wrist.
Hyperpronation technique. Hold the elbow at 90 degrees,
then firmly pronate the wrist.
After successful reduction, relief is immediate, and the child
is typically moving the affected extremity within 5 to 10 minutes.
If spontaneous improvement is not noted within 30 minutes, obtain
radiographs to rule out a possible fracture. If findings on plain
radiographs are negative for acute fracture and the child is still
reluctant to use the arm, immobilize the arm in a sling and arrange
orthopedic follow-up within 1 week for reassessment.
Macias CG, Bothner J, Wiebe R: A comparison of
supination/flexion to hyperpronation in the reduction of
radial head subluxations. Pediatrics 102(1): 110,