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Pulled Elbow/ Nurse Maid’s Elbow

It is subluxation of radial head or more accurately subluxation of the annular (orbicular) ligament which slips up over the head of radius into the radiocapitellar joint.
  1. Mechanism of Injury
  1. Forearm is pronated, elbow is extended and longitudinal traction is applied to the patients wrist or hand.
  2. Such an injury typically occurs when
    1. A young child is lifted or swung by the forearm.
    2. A child suddenly steps down from a step or off a crub while one of the parents is holding the hand or wrist.
  1. Clinical Feature
    1. Common in children <4 years and rare in >5 years. (because the annular ligament is thicker or stronger) with maximum incidence in 1-4 years age group.
    2. The child holds the elbow in slight flexion with the forearm pronated.
    3. Supination is limited and voluantrily resisted.
    4. Flexion of elbow is painless
    5. A click may have been heard or felt by a person who pulled it.
    6. Radiographs are normal
  2. Treatment
    1. Reduced by flexing the elbow to 900 and rapidly & firmly rotating the forearm into full supination.
    2. lmmobilization is not necessary
    3. Classically the head of radius should not be excised in children because
      1. It will interfere with the synchronous growth of radius and ulna producing wrist & elbow deformity.
      2. It leads to proximal radial migration & subluxation of inferior radio ulnar joint.
      3. It causes weakness of extremity & discomfort in distal radioulnar joint with heavy activities
      4. May produce cubitus valgus deformity and instability.
Treatment Plan of Fracture Head of Radius
  1. Undisplaced split: Immobilization in above elbow POP with cuff & collar sling.
  2. Single large displaced articular (inner 2/3rd) fragment: Reduction & Herbert screw (Headless screw) fixation.
  3. Small, displaced nonarticular (outer 1/3rd) fragment: Outer 1/3’’ part of radial head is nonarticular, so open reduction is usually not required as it is often only excised.
  4. Comminuted fracture: Excision of radial head & prosthetic replacement.

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