Trends and epidemiology of radial head subluxation in the United States from 2004 to 2018.

BACKGROUND: Increased body mass may predispose children to a greater risk for radial head subluxation (RHS). Recent studies in the literature have reported a plateau in obesity prevalence among infants and toddlers. This study sought to examine recent epidemiological trends in RHS incidence from 2004 to 2018 using the National Electronic Injury Surveillance System database to determine how obesity patterns may affect RHS incidence. METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried for patients 6 years of age or younger presenting with radial head subluxation between January 1, 2004 and December 31, 2018. Patient demographics, mechanisms of injury, and location of injury were recorded. RESULTS: An estimated total 253,578 children 6 years or younger were treated for RHS with 14,204 (95% CI = 8124-20,284) in 2004 to 21,408 (95% CI = 12,882-29,934) in 2018. The overall annual rate of RHS per 10,000 children ≤ 6 years was 6.03 (95% CI = 4.85-7.58). The annual rate of RHS per 10,000 children ≤ 6 years increased (m = 0.200, ß = 0.802, p < 0.001) from 5.18 (95% CI 2.96-7.39) in 2004 to 7.69 (95% CI = 4.63-10.75) in 2018. The most common mechanism associated with RHS was falls (39.4%) with 103,466 (95% CI 74,806-132,125) cases. Pulls accounted for the second most common mechanism of injury, accounting for 90,146 (95% CI 68,274-112,018) cases or 36.2%. Yearly RHS incidence was compared to obesity prevalence for ages 2-5 children provided by the National Health and Nutritional Examination Survey (NHANES) surveys. Changes in obesity prevalence may visually reflect RHS incidence trends, but no causality between obesity prevalence and RHS incidence could be confirmed. CONCLUSION: This study corroborated previous findings that falls and arm pulling contribute to the vast majority of RHS cases. The nonsignificant rise in RHS cases may reflect a possible plateau in obesity prevalence of children aged 2-5 years in recent years. LEVEL OF EVIDENCE: III.

Role of the supinator muscle in the pathophysiological mechanism of a pulled elbow.

A pulled elbow is a common childhood orthopaedic injury that is usually caused by longitudinal traction on the hand. The pathophysiological mechanism of a pulled elbow involves interposition of the annular ligament into the radiohumeral joint. Recent ultrasonographic studies have shown that both the supinator muscle and annular ligament were trapped into the radiohumeral joint. This paper discusses why pulled elbows can occur during pronation and how a pulled elbow can be reduced either by hyperpronation or supination followed by elbow flexion based on the function of the supinator muscle.

Hyperpronation versus Supination-Flexion in Radial Head Subluxation Reduction: A Randomized Controlled Trial.

Radial head subluxation (RHS) is the most common upper extremity injury in children. Supination-flexion (SF) and hyperpronation (HP) are two methods for reducing this subluxation. This study purposed to compare the success rates of two methods of reduction and also to determine which technique would be less painful. In total, 154 patients with RHS were enrolled in this study and randomized into two groups. Patients were to undergo reduction by one of the two methods; if the primary attempt was unsuccessful, a second attempt was performed using the alternate technique. In the case of failure of the second attempt, the first reduction technique was repeated. The success rates and pain levels before and after successful reduction were recorded. On the first attempt, 72 of 77 patients who underwent HP had a successful reduction. Four patients in the HP group had a successful reduction on the second attempt. In the SF group, 76 of 77 patients had a successful reduction on the first attempt. The success rate on first attempts was higher in the SF group than in the HP group ( p = 0.043). Pain levels before and after reduction were not statistically different between the groups ( p > 0.05). The SF technique had a higher success rate at first attempt to reduce RHS, but pain levels were similar in both methods.

Radial head subluxation in pediatric clinics and emergency departments in China.

PURPOSE: To investigate the characteristics of the onset and treatment of radial head subluxation (RHS) in pediatric clinics and emergency departments. METHODS: A retrospective study was performed on 11, 404 RHS cases in 9827 children who visited pediatric clinics and emergency departments from January 2015 to December 2018. The patients who with history of trauma and fracture of the affected limb were excluded. The following factors were examined: the mechanisms of RHS, the type of manual reduction, the attending physician's clinical background (emergency surgeon, junior pediatric orthopedic surgeon or senior pediatric orthopedic surgeon), and the epidemiological features (gender, age, climate and location) of the injury. RESULTS: The mean age of the patients was 27.93 ± 17.94 months (range 0.93-214.53 months), with a peak incidence of 10.73-44.53 months. Approximately two-thirds of RHS cases occurred in cold weather from January to March and from September to December. Females accounted for 53.81% (n = 6137) of the cases, and left injuries were predominant (56.87%, n = 6485) in all cases. Mechanisms of injury were classified as "pull" (90.57%, n = 10, 339), "fall" (1.56%, n = 178), "hit" (0.75%, n = 86) and "unknown" (7.02%, n = 801). The overall success rate of manual reduction was 99.47%, and the success rate of reduction was higher for senior pediatric orthopedic surgeons than for emergency surgeons and junior pediatric orthopedic surgeons (p < 0.05). However, there was still a recurrence rate of 12.16% in the 9827 patients. CONCLUSION: Younger children are predisposed to RHS, and there is a possibility of recurrence. Trained emergency doctors can handle it well, but it is essential to refer patients to specialists when manual reduction failed.

Nursemaid's Elbow - Supination-flexion Technique Versus Hyperpronation/forced Pronation: Randomized Clinical Study.

BACKGROUND: Nursemaid's elbow (NE) represents the most common pathology met in the pediatric orthopedics ambulatory. There are two techniques of reducing the NE: the supination-flexion technique and the hyperpronation or forced pronation technique. MATERIALS AND METHODS: In this randomized clinical study, we aim to compare the two reduction techniques of the NE, by measuring the effectiveness of each and scaling the pain felt by the child, by using the Faces Pain Scale. The study included 116 patients with typical presentation for NE with age under 7 years old (mean age ~3 years old), 45% of males and 55% of females. RESULTS: Hyperpronation was found to be more successful than supination-flexion technique as a first attempt (85% vs. 53%), second attempt (50% vs. 28%), and as a crossover technique (100% vs. 50%) when supination-flexion failed. CONCLUSIONS: This study concludes that hyperpronation technique should be used as a first maneuver reduction in treating NE, a simple one-movement technique.

Radial head subluxation in pediatric clinics and emergency departments in China / 中华创伤杂志(英文版)

Purpose:@#To investigate the characteristics of the onset and treatment of radial head subluxation (RHS) in pediatric clinics and emergency departments.@*Methods:@#A retrospective study was performed on 11, 404 RHS cases in 9827 children who visited pediatric clinics and emergency departments from January 2015 to December 2018. The patients who with history of trauma and fracture of the affected limb were excluded. The following factors were examined: the mechanisms of RHS, the type of manual reduction, the attending physician's clinical background (emergency surgeon, junior pediatric orthopedic surgeon or senior pediatric orthopedic surgeon), and the epidemiological features (gender, age, climate and location) of the injury.@*Results:@#The mean age of the patients was 27.93 ± 17.94 months (range 0.93-214.53 months), with a peak incidence of 10.73-44.53 months. Approximately two-thirds of RHS cases occurred in cold weather from January to March and from September to December. Females accounted for 53.81% (n = 6137) of the cases, and left injuries were predominant (56.87%, n = 6485) in all cases. Mechanisms of injury were classified as "pull" (90.57%, n =10, 339), "fall" (1.56%, n = 178), "hit" (0.75%, n = 86) and "unknown" (7.02%, n = 801). The overall success rate of manual reduction was 99.47%, and the success rate of reduction was higher for senior pediatric orthopedic surgeons than for emergency surgeons and junior pediatric orthopedic surgeons (p < 0.05). However, there was still a recurrence rate of 12.16% in the 9827 patients.@*Conclusion:@#Younger children are predisposed to RHS, and there is a possibility of recurrence. Trained emergency doctors can handle it well, but it is essential to refer patients to specialists when manual reduction failed.

Parental questionnaire study showed that annular ligament displacement was common in three-year-old children and almost a half had reoccurring episodes.

AIM: This study sought to determine the incidence of annular ligament displacement (ALD), also known as nursemaid's elbow, in the first 3 years of life. METHODS: A questionnaire was sent to 1098 families between August 2014 and July 2015 before their child attended a routine health check at 3 years of age in Izumo, Shimane prefecture, Japan. The questionnaire included a brief description about ALD, the age when ALD occurred and how the condition was managed. RESULTS: We received 784 (71.4%) responses and these showed that 61 (7.8%) children had a history of ALD and 31 (51%) were girls. The incidence was 2.6%, calculated by multiplying the number of children by the 3-year observation period. The mean and median ages of the first ALD occurrence were both 25 months. In addition, 28 (46%) children with ALD had a recurrence and the mean number of ALD episodes was 1.8 (range 1-5). The total number of ALD episodes was 108, and of these, 33 (30%) were seen at the hospital emergency department and 17 (16%) spontaneously resolved. CONCLUSION: This study confirmed that ALD was a common occurrence in 3-year-old children and that there was a high rate of recurrence.

Modyfied wedge osteotomy for osteoarthritis of elbow secondary to osteochondritis dissecans in adolecent with multiple epiphyseal dysplasia. A case report.

Multiple epiphyseal dysplasia (MED) may be complicated by osteochondritis dissecans (OCD), most commonly reported in the knee, but involvement of the elbow is very rare. Optimal treatment for MED-associated elbow OCD and treatment outcome have not been established. This report describes the case of an adolescent male patient with elbow OCD treated by arthroscopic drilling at a previous clinic. Progression of osteoarthritis and radial head subluxation were observed. Resection of the osteophytes and modified wedge osteotomy of the lateral condyle were then performed, and a favorable result was obtained by decompression and sufficient congruency of the radiohumeral joint.

Radial Head Subluxation Among Young Children in the United States Associated With Consumer Products and Recreational Activities.

This study investigated the epidemiology of children treated in US emergency departments for radial head subluxation (RHS) associated with consumer products and recreational activities using data from the National Electronic Injury Surveillance System. An estimated 430 766 (95% confidence interval: 341 194-520 339) children ≤5 years of age were treated for RHS in US emergency departments from 1990 to 2011. The mean patient age was 2.1 years, and 56.5% of patients were girls. The most common mechanism of injury was a fall (43.2%), followed by arm pull (39.4%). The annual rate of RHS increased significantly by 190.1% during the 22-year study period. This is the largest study of RHS to date and the first to use a nationally representative sample to investigate secular trends and mechanisms of injury for RHS associated with consumer products and recreational activities. Events associated with consumer products and recreational activities are an important increasing source of RHS.

Pulled/nursemaid's elbow.

Nursemaid's elbow is a radial head subluxation caused by axial traction on the extended arm while the forearm is pronated, allowing for slippage of the radial head. A 2-year-old boy presented with pain, swelling and reduced range of movement of the right elbow for 4 days. The mother noted that the child was moving the right upper limb less often and there was tenderness over the right elbow. X-ray of the right elbow showed subluxation of the elbow joint with no obvious fracture. A trial of conservative management was decided upon and the patient was placed on a right elbow backslab with the right forearm in a supine position. On follow-up, there was no swelling, tenderness or neurological deficit noted. A repeate x-ray revealed normal findings.

Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis.

BACKGROUND/AIM: Nursemaid's elbow usually occurs in young children when longitudinal traction is placed on the arm. Several manipulative maneuvers have been described, although, the most effective treatment technique is yet unclear. The aim of this systematic review and meta-analysis was to compare the two most commonly performed maneuvers (supination-flexion and hyperpronation) in the treatment of nursemaid's elbow. METHODS: A literature search was performed in PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing supination-flexion and hyperpronation. Data were extracted and pooled independently by two authors. Methodological quality assessment of included studies was performed. Meta-analysis was performed using a fixed-effect model in case of homogeneity across studies, and using a random-effect model in case of heterogeneity. Heterogeneity was calculated with the χ2 test and inconsistency in study effects across trials was quantified by I2 values. RESULTS: Seven randomized trials, including 701 patients (62% female), were included. A total of 350 patients were treated with the hyperpronation maneuver versus 351 patients who underwent the supination-flexion maneuver. Meta-analysis showed that hyperpronation was more effective than supination-flexion (risk ratio, 0.34; 95% confidence interval, 0.23 to 0.49; I2, 35%). The absolute risk difference between maneuvers was 26% in favor of hyperpronation, resulting in a number needed to treat of 4 patients. Trials lacked blinding of assessors and universal pain measures. CONCLUSIONS: Hyperpronation was more effective in terms of success rate and seems to be less painful compared to the supination-flexion maneuver in children with nursemaid's elbow.

Ultrasonic diagnosis of radial head subluxation and clinical value / 中国医学影像技术

Objective To investigate the diagnostic value of ultrasonography in radial head subluxation (RHS).Methods The clinical data and ultrasonographic findings of 34 children with RHS were retrospectively analyzed.All patients were routinely treated by bilateral compared and multi-sectional elbow joints ultrasonography.And the X ray results were negative.Results Ultrasonographic manifestations of RHS included increased radiocapitellar distance in 29 cases (29/34,85.29％);widened joint space and enhanced echo in 25 cases (25/34,73.53％);hook sign,supinator muscle above the radial head in 32 cases (32/34,94.12 ％);annular ligament entrapment in 33 cases (33/34,97.06％).Conclusion Ultra sonographic manifestations of RHS have certain characteristics.Comparation of bilateral elbow joints and the application of continuous scanning ultrasound are helpful to make a quick and accurate diagnosis of X-ray negative RHS.

Pulled/nursemaid’s elbow

Nursemaid’s elbow is a radial head subluxation caused by axial traction on the extended arm while the forearm is pronated, allowing for slippage of the radial head. A 2-year-old boy presented with pain, swelling and reduced range of movement of the right elbow for 4 days. The mother noted that the child was moving the right upper limb less often and there was tenderness over the right elbow. X-ray of the right elbow showed subluxation of the elbow joint with no obvious fracture. A trial of conservative management was decided upon and the patient was placed on a right elbow backslab with the right forearm in a supine position. On follow-up, there was no swelling, tenderness or neurological deficit noted. A repeate x-ray revealed normal findings.

Prevalence of Capitellar Osteochondritis Dissecans in Children With Chronic Radial Head Subluxation and Dislocation.

OBJECTIVE: An abnormal radiocapitellar articulation may play a role in the development of capitellar osteochondritis dissecans (OCD). The objective of this study is to determine the prevalence of capitellar OCD in pediatric patients with chronic radial head subluxation (RHS) or radial head dislocation (RHD). MATERIALS AND METHODS: We searched the radiology reports generated at a large pediatric hospital between 2004 and 2012, to identify patients 8-18 years old with chronic RHS or RHD. Patients with underlying bony abnormalities that could obscure, be confused with, or increase the risk of OCD of the elbow were excluded. Two pediatric radiologists assessed images of the elbow, grading radiocapitellar alignment as follows: normal, subluxed, dislocated, or intermittently subluxed and dislocated. Readers also reviewed images to detect capitellar OCD. The differences in the prevalence of OCD noted in elbows in each category of radiocapitellar alignment were assessed. RESULTS: A total of 118 cases of chronic RHS, RHD, or both were detected in 100 patients. The radiocapitellar alignment of these cases was defined as follows: 53-58% were dislocated, 26-31% were subluxed, 14-15% were intermittently subluxed and dislocated, and less than 1% had normal alignment. There were 14 cases of capitellar OCD (11.9%). One elbow with OCD was categorized by both readers as dislocated, with the remaining 13 elbows (93%) deemed by the two readers to be either subluxed or intermittently subluxed and dislocated. The percentage of elbows with RHS that were found to have capitellar OCD was 32.3-33.3%, compared with 1.4-1.6% of elbows with RHD. CONCLUSION: The prevalence of capitellar OCD is greater in elbows with RHS than in those with RHD. This finding suggests that abnormal radiocapitellar mechanics are a factor in the development of OCD. In children with RHS and new or worsening pain, capitellar OCD should be considered, and imaging strategies should be directed toward early identification of this important and treatable condition.

Suggestion of a Modified Reduction Maneuvers with Parents in the Pulled Elbow Children

PURPOSE: If radial head subluxation, otherwise known as pulled elbow, occurs, closed reduction can be used in simultaneous diagnosis and treatment of the child. As the guardian seldom understands the maneuver without explanation, we revised a method to involve the caregiver in the treatment. METHODS: This was a prospective controlled study. From January, 2014 to December, 2014, children suspected of radial head subluxation, under the age of 6, were enrolled. Patients were randomly assigned to two groups. One group was treated conventionally and the other group was treated while the parent's finger was on the patient's lateral epicondyle. A total of three attempts were made using the hyperpronation method and the supination-flexion method. The physician then recorded whether the treatment was successful, the number of attempts, easiness of the reduction, and guardian's degree of understanding and satisfaction. RESULTS: A total of 116 patients were enrolled. The number of attempts was 1.27 and 1.35 times in the experimental group and the control group, respectively. The success rate was 96.6% in the experimental group and 94.7% in the control group. There was no statistically significant difference within the two groups. The physicians found that the revised method was as easy as the conventional method and the caregiver's degree of understanding was higher in the experimental group. CONCLUSION: As the revised method increases the degree of guardians' understanding and does not increase the difficulty of the procedure, we recommend using the revised method in treatment of radial head subluxation.

Investigation on 2331 cases of pulled elbow over the last 10 years.

Pulled elbow is a common upper extremity injury in children. We present a retrospective study of 2331 pulled elbow cases examined in our hospital over the last ten years. All pediatric patients with a diagnosis of pulled elbow from January 2002 to December 2011 were retrospectively reviewed according to sex, age, affected arm, recurrence rate, mechanism of injury and treatment outcomes. There is no significant sex difference. The frequency of injury peaked for both boys and girls at 6 months and 2 years of age. The left arm was more affected than the right. The recurrence rate was 14%. In about 50% of cases, the cause of injury was forcible traction to the forearm. Almost all of the splinted patients, caused by severe pain or lack of mobility of the affected limb following reduction, recovered within 2 weeks, but 2 were later diagnosed with a fracture. For infants less than 1 year old, injury can often occur when rolling over. For children 1 year old or older the left arm is more commonly affected, and the frequency of injuries to the left arm increases with age, possibly because the left hand is commonly held by the guardian's dominant right hand and faster development of muscle strength in the child's dominant right arm works toward preventing injury to that arm with age.

Application of high frequency ultrasonography in the diagnosis of irreducible radial head subluxation in children / 中华超声影像学杂志

Objective To explore the application of high frequency ultrasonography in the rapid diagnosis of irreducible radial head subluxation in children.Methods Twenty-three patients aged 1 to 5 with unilateral radial head subluxation in children were observed by high-frequency ultrasonography and radiography,and then compared the symptomatic to the contralateral side.Results No case of radial head subluxation was found by radiography.23 cases of radial head subluxation were found by high frequency ultrasonography,10 cases with articular cavity effusion.On the diagnosis of radial head subluxation in children,the sensitivity of high frequency ultrasonography was obviously higher than that of radiography.Conclusions The sensitivity of high frequency ultrasonography in the rapid diagnosis of the radial head subluxation in children is obviously higher than that of X ray film.High frequency ultrasonography through continuous scan can determine the continuity of anatomical structure and the relationship between some views to show the location of the specific structure relations.Specifically,it can be quickly and clearly diagnosed on anterior long-axis view and the lateral coronal view of radiohumeral joint.