REVIEW ARTICLE
103
SUBLUXATION
OF
THE
HEAD
OF
THE
RADIUS
IN
YOUNG
CHILDREN
By Max E. Griffin, B.S., M.D.*
S
tYBLUXATION of the head of the radius isa fairly frequent traumatic condition
which is apparently not generally
recog-nized or diagnosed. It has been called by
a variety of names, including: dislocation
by elongation; subluxation of young
chil-dren; slipped elbow of young children;
pulled elbow; Gromeyer’s injury;
Mal-gaigne’s luxation; painful elongation of
young children; curbstone fracture, and
nursemaid’s elbow.
The cause is traction upon the extended
arm at the hand or wrist of a young child,
usually under 4 years of age. Examples of
this are in lifting a child up over a curb,
holding him when he stumbles, pulling the
arm through the sleeve of a dress or sweater,
pulling a toy away from a child, or swinging
a child around by the hands. Occasionally
the injury may be sustained in a fall, in
which case the history may be misleading.
The child usually cries out at once with
pain and refuses to use the arm which may
hang motionless by the side, but it is usually
held with the forearm flexed 15#{176}to 20#{176}and
about three-fourths pronated. Examination
reveals pain on pressure over the head of
the radius. There may or may not be some
swelling over the radial head depending
upon the duration of the subluxation. There
may also be some pain at the wrist or
shoulder for which no explanation has ever
been found. The hand, wrist and shoulder
can be moved in any direction by the
ex-aminer. The elbow can usually be moved
From the Children’s Hospital, Akron, Ohio. Thesis accepted by the Faculty of the Graduate School of Medicine of the University of Pennsyl-vania for the Degree of Master of Medical Science, for graduate work in Pediatrics.
0 ADDRESS: 10343i Wooster Road, N., Barberton,
Ohio.
in all directions, but supination of the
fore-arm usually meets resistance and causes
pain in the elbow. Recurrences are not
un-common, especially in children of frail
stature and poor musculature.
REVIEW OF THE LITERATURE
The syndrome of subluxation of the head
of the radius was recognized and accurately
described as early as 1671 by Foumier.’ He
described the injury as an incomplete
dis-location characterized by relaxation of the
ligaments and downward separation, or
elongation, of the radius. Nearly a hundred
years later Duverney2 gave a clear and exact
description of it as an injury occurring
fre-quently in children. He attributed it to
forci-ble traction at the wrist and gave as its chief
symptom the opposition to supination of the
forearm. His treatment consisted of forcible
supination with pressure upon the head of
the radius followed by flexion of the elbow.
He thought the injury was not merely an
elongation of the radius but also the escape
of its head below the edge of the orbicular
ligament.
During the Nineteenth Century, this
con-dition was a favorite subject of French and
German writers. Much controversy existed
over the cause of this condition. These
dis-cussions were all well summarized by
Slim-son3 in 1912. In addition, there were
spo-radic reports by English and American
writ-ens. These include Gardner,4 Poinsot,5
Moore,6 Cushing,7 and Van Santvoordt.8
In 1899 Van Arsdale9 presented the only
large series of patients. He saw 100 patients
in a 2-year period of dispensary practice.
He stated that these 100 cases represented a
frequency of 0.5 per cent for children under
10 years of age with all ailments and
104 GRIFFIN - SUBLUXATION
ages. His youngest patient was 3 months of
age and the oldest 9 years of age.
Ston&#{176}in 1916 reported his observations
on the pathology following extensive
ana-tomic experiments on cadavers. He
con-eluded that the deformity was caused by the
head of the radius slipping under the
an-nular ligament. He demonstrated that the
head could slip out only if the forearm was
pronated. Anteriorly from the neck of the
radius to the head the rise is an abrupt
one. Any traction with the hand supine pulls
the ligament against the head. Laterally and
posteriorly the ascent is quite gradual so
that in pronation the ligament lies over the
lateral aspect of tile radius and, as the
liga-ment is gradually stretched, it suddenly
slips over the head. Stone’s discussion is
quite convincing and is generally accepted
as the explanation. There are 2 other factors
that support his theory: the ossification
center of the head of the radius does not
appear until the fifth year of life11 so that
this portion of the radius is more pliable
and can more easily slip tinder the annular
ligament, and, secondly, the navicular bone
bone does not ossify until the sixth year of
life.” These 2 points might explain why
the radius is able to move distally without
meeting bony obstruction and why
subluxa-lion rarely occurs past the sixth year of life.
In addition, it is between the ages of 2 and 5
that the child is walking around, frequently
being lifted by the hand by taller
mdi-viduals, thus making the highest incidence
of subluxation in this age group.
There have been a few more recent
re-ports, all of which stress the frequency of
this condition. Andersonll in 1942 reported
13 patients he had seen in private practice
in a 6-year period. Boyette and Londonll in
1948 reported 2 patients, implying they had
seen more. Smith14 in 1949 reported 5
pa-tients and McVeagh15 in 1951 reported 6
patients seen over a period of 4 years.
Kanter and Bnuton16 reported 5 patients
seen in a 6-month period. Most of these
re-ports have been in journals with a rather
limited circulation. In addition, modern
textbooks of pediatnics179 and surgery20’ 21
fail to describe this syndrome. Although this
is a situation involving bone and joints, it
is a pediatric problem and most often will
be seen initially by the pediatrician or
gen-eral practitioner. Renewed emphasis should
be placed upon this condition which once
was well known. Diagnosis is easy if kept
in mind. Treatment is simple and can be
done by anyone making the diagnosis, thus
avoiding expensive and time consuming
referrals.
CASES, TREATMENT AND DISCUSSION
During an 8-month period (June, 1950,
through January, 1951), a total of 8,635
pa-tient visits was recorded in the Emergency
Room of the Children’s Hospital, Akron,
Ohio. This included children up to the age
of 15 years. Of this number, 4,024 were
classified as true emergencies (accidents,
fractures, bums, poisonings, etc.). Of these
emergencies, 75 patients with subluxation
of the head of the radius were discovered.
This is an incidence of 1.8 per cent of the
emergency cases and represents an average
of over 2 per week, obviously not an
un-common occurrence.
The youngest child seen with this
condi-tion was 4 months of age, and the oldest was
7% years of age. Table I shows the number
TABLE I
Age Group.? Number of
Patient.?
1 year and under 6
I year to ‘2 years 3
2years to S years 7
Syears to 4 years 14 4years to 5 years
.5years to 6 years I
6 years to 7 years I
7years to 8 years I
Total 7.5
of patients in each age group. The average
age was 2% years. Almost 85 per cent of the
patients seen were between the ages of 1
and 4 years. Forty-two of the patients were
females and 33 were males. Seventy of the
Negroes. Four of the children had had 1
previous occurrence, and 1 child had had 2
previous occurrences. These statistics closely
approximate those quoted froni the
litera-tune.
Stone1#{176}has stated that if x-rays of both
elbows are compared a difference may be
noted on the affected side. In 1 patient
he demonstrated the head of the radius on
the affected arm to be farther from the
capitellum than on the normal side, but the
difference was slight. McVeagh’5 noted in 1
patient a very slight degree of lateral
dis-placement of the head of the radius on the
nina when premanipulative x-rays were
compared with the postmanipulative x-rays.
None of the other writers have described
any x-ray changes. N-rays were taken on 11
of the patients in our series and no
signifi-cant variation could be detected. It is our
l)elief that the diagnosis can be made from
the typical history, examination, and
re-spouse to treatment. However, it is
recom-mended that x-rays be obtained to rule out
the existence of some more serious
condi-tion.
All of the patients in this series were
re-duced in the following manner. The
fore-arm was flexed to an angle of almost 90#{176}
with the examiner’s thumb placed over the
head of the radius. The arm was then
su-pinated Witil pressure being exerted over
the radial head. As the head of the radius
slipped under the annular ligament, a
dis-tinct click was usually felt and/or heard.
This click was detected in all but 3 of the
patients in this series. All the children were
able to use the affected arm immediately
after reduction. It was felt unnecessary to
put tile arm in a sling. It has been stated
that, if tile subluxation has existed more
than 24 hours, there will be some reluctance
of the child to use the arm immediately
fol-lowing reduction until the swelling and
pain have subsided. In such patients, it
would probably be wise to put the arm in
a sling for a few hours.
Stimson3 states that some patients
prob-ably reduce spontaneously and are never
seen by a physician. Cleary, quoted by
Mc-Veagh,15 believes that in many instances the
subluxations may spontaneously reduce
while sleeping. It was not unusual in our
experience for the reduction to occur while
the x-ray technician was positioning the arm
for the x-rays.
Most writers have stated that subluxation
of the head of the radius is a very benign
condition. However, Stimson3 mentions in
his article that there is reason to think some
cases of forward dislocation of the head of
the radius found in adults, which had
ex-isted from childhood, were originally
sub-luxations and that the radial head had
gradually become displaced further
for-ward. One of the patients reported by
Mc-Veagh15 was a 13-year-old child with a
de-formity of the elbow. He thought this was
the end result of unreduced subluxation of
the head of the radius. Blodgett22 reported
2 patients with “congenital luxation of the
head of the radius” which appeared to have
deformities resulting from failure of
reduc-tion of a subluxated radial head. No such
deformities have been detected in our
series, although the follow-up has been
neither long nor comprehensive. It is our
opinion that if the reduction is
accom-plished there is little chance for such
de-formities to occur.
SUMMARY
Subluxation of the head of the radius is a
fairly frequent traumatic injury of children
under the age of 4 years. The history is
al-most always the same-that of traction on
the extended arm. Examination reveals a
painful elbow and when the forearm is
forcibly supinated, reduction occurs
accom-panied by an audible or palpable click.
Re-currences are not unusual. Reduction may
occur spontaneously. If reduction is not
ob-tamed, a permanent deformity of the elbow
may result. Diagnosis and treatment can
and should be done by pediatricians and
general practitioners.
ADDENDUM
Since this paper was written, 9 additional
prac-106 GRIFFIN - SUBLUXATION
tice (luring the period from June, 1951, to
May, 1954. The ages ranged from 6 months
to :3 years. One of the children had had 1
previous occurrence. All of these cases had a
typical history and were easily reduced with
a detectable click.
REFERENCES
1. Fournier, D. : L’Oiconornie Chirugicale.
Paris, Francois Clouzier, Robert De
Ninzille, et Cebastian Cramoisy, 1671,
p. 250.
2. Duverney, C.
J.
: Traite des Maladies desOs. Paris, Chez de Bore L’Aime, 1751.
3. Stimson, L. A. : Fractrres and
Disloca-tions, 7th Ed. Philadelphia, Lea and
Febiger, 1912, pp. 730-734.
4. Gardner, A. : On an undescribed displace-ment of the bones of the forearm in
chil-dren. London Med. Gaz., 20:878, 1837.
5. Poinsot, C. : Dislocation of the head of
the radius downward, New York Med.
J., 41:8, 1885.
6. Moore, E. M. : Subluxation of the radius
from extension in young children. Trans.
New York State Med. Assn., 3:18, 1886.
7. Van Santvoord, R. : Dislocation of the
head of the radius by elongation. New
York Med. J., 45:63, 1887.
8. Cushing, H. W. : Subluxation of the radial
head in children. Boston M. & S. J.,
114:77, 1886.
9. Van Arsdale, W. W. : On subluxation of
the head of the radius in children with
resume of 100 consecutive cases. Ann.
Surg., 9:401, 1889.
10. Stone, C. A., Jr. : Subluxation of the head of
the radius. J.A.M.A., 67:28, 1916.
1 1. Gray, H. (edited by W. H. Lewis):
Anat-omy of the Human Body, 24th Ed.
Philadelphia, Lea and Febiger, 1946,
pp. 212 and 222.
12. Anderson, S. A. : Subluxation of the head
of the radius, South. M. J., 35:286,
1942.
13. Boyette, D. P., and London, A. H., Jr.:
Subluxation of the head of the radius,
“nursemaid’s elbow.” J. Pediat., 32:278, 1948.
14. Smith, E. E. : Subluxation of the head of
the radius in children. Ohio State M. J.,
45:1080, 1949.
15. MeVeagh, T. C. : The “slipped elbow” of
young children. California Med., 74:
260, 1951.
16. Kanter, A. J., and Bruton, 0. C. :
Subluxa-tion of the head of the radius. Am.
Pract., 3:39, 1952.
17. Nelson, W. E. : Textbook of Pediatrics,
6th Ed. Philadelphia, W. B. Saunders
Co., 1954.
18. Holt, L. E., and McIntosh, R. : Pediatrics,
12th Ed. New York, Appleton, 1953.
19. McQuarnie, I. : Brenneman’s Practice of
Pediatrics. Hagerstown, Prior, 1949.
20. Christopher, F. : Minor Surgery, 6th Ed.
Philadelphia, Saunders, 1948.
21. Cole, W. H., and Elman, R. : Textbook of
General Surgery, 5th Ed. New York,
Appleton, 1948.
22. Blodgett, W. E. : Congenital luxation of
the head of the radius. Am. J. Orthop.
