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Radial Head Subluxation: Fall Is A Frequent Mechanism Of Injury In 512 Cases

Grauel F, Rothe K, Maerzheuser S
Departement of Pediatric Surgery, Charité, University Hospital, Berlin, Germany

 

Abstract

The objective of this study was to determine the risk of radial head subluxation (RHS) as a consequence of fall and to describe the characteristics for this group of patients.

Material and Methods Charts of all patients discharged from the emergency room with a diagnosis of RHS were retrospectively reviewed. Cases were identified using the injury section of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD- 10). All cases with a final discharge diagnosis consistent with RHS were included in the study; cases of elbow dislocation and/or fracture were excluded.

Results In 512 patients, fall accounted for 17% in all age groups, and 24% in children aged 4 years and more. 24% of patients were evaluated radiographically, 70% of those had a history of fall and 13,6% had an unclear history. In boys fall was the mechanism of injury in 21 %, in girls a causative fall was found in 13%. Reduction was successful by first attempt in 96%.

Conclusion: This study demonstrates that a history of a pull only accounts for 58 % of all cases of RHS. Fall accounted for 17 % of the injury over all age groups and was more frequent in children aged 4 years and more (24%). Reduction is easy and rapid and successful by first attempt in 96 %.

Key words: radial head subluxation – mechanism ofinjury – pediatric – fall

 

Correspondence

S. Maerzheuser
Department of Paediatric Surgery, Charité University Hospital, Berlin, Campus Virchow Clinic,
Augustenburger Platz 1, 13353 Berlin, Germany
Phone: +49 30 450 666 639,
Fax: +49 30 450 566 905
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Introduction

Radial head subluxation (RHS) also known as Chassaignac`s paralysis, pronatio dolorosa infantum, subluxatio radii per anularis, nursemaid elbow or pulled elbow is one of the most common upper extremity injuries in young children and a common reason for an emergency department (ED) visit [18].

While children may sustain this injury up to about 7 years of age, typically they are between the ages of 1 and 3 years [15,16,21,]. It is a pseudoparesis of the lower arm in small children, that is not painful if the forearm is not manipulated.

Pathophysiology is supposed to be a radial head subluxation that can be either with an interposed radial annular ligament [11,16,18] or torn ligament [4]. Treatment consists of supination of the forearm and flexion of the elbow with moderate pressure over the head of the radius or hyperpronation [13,17,20]. Successful treatment is often accompanied by a characteristic click and should be followed by immediate return of function.

Traction is considered as the cause of injury [1,2,15,17,18,21] but based on clinical encounter fall also seems to be a frequent mechanism of injury. The objective of our study was to determine the risk of RHS as a consequence of fall. We also sought to describe the characteristics for this group of patients

Materials and Methods:

We conducted a retrospective medical record review of all patients presenting to the pediatric emergency room over a 1-year period between August 1.2006, and August 31, 2007. This review was conducted at the department of pediatric surgery of the Charité University Hospital in Berlin.

We reviewed the charts of all patients discharged from the emergency room with a diagnosis of RHS. Cases were identified using the injury section of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). All cases with a final discharge diagnosis consistent with RHS were included in the study; cases of elbow dislocation and/or fracture were excluded.

To improve accuracy and minimize inconsistencies in the chart review, the review was performed by one of the investigators using a standard data abstraction form to extract the following variables: age, sex, causative mechanisms, clinical picture, physical examination, treatment and radiographic findings. Causative mechanism was analysed and categorized as pulled, twisted, fallen or unclear. Parents were asked if the child had had this condition before. The Clinical picture had to contain the following elements: a child with an elbow slightly flexed with the forearm held against the abdomen, the child showed no signs of pain if the arm was not manipulated and was playing with the contralateral hand. The patients moved the arm at the shoulder but resisted to move the elbow or to grab anything by the hand. There were no clinical signs of fracture such as dislocation, swelling or hematoma. If there was no record of these variables, they were recorded as being “not documented.” Charts with unclear diagnosis were excluded. All variables on the data abstraction form were discussed and defined by the study team prior to the chart review. Data analysis was performed using SPSS 14.0 for Windows. Descriptive statistics and frequencies were used to analyze the variables.

Results

We reviewed 11000 charts of pediatric surgical patients that had been treated in the emergency room the within the period of 12 month.

512 patient files were included in the study. The youngest patient was 1 month old and the oldest patient was 12 years old. The median age was 26 month and the average 29.52 months. 289 (56%) patients were female and 223 (44%) were male. We found a slight predominance in females. Table 1 shows the characteristics of the children in the study.

Table 1. Characteristics of patients with radial head subluxation

Characteristic

No. (%) of patients

Sex

Female

289 (56%)

Male

223 (43.1%)

History of RHS (n = 432)

Yes

55 (12,7%)

No

 377 (87,2%)

Mechanism of injury (n = 512)

Pull

298 (58%)

Unknown

104 (20%)

Fall

84 (17%)

Twist

26 (5%)

Radiograph of ellbow (n= 125)

History of Fall

88 (70%)

Unclear History

17 (13,6%)

Unsuccessfull reduction

20 (16%)

 

Spontaneous reposition

51 (10%)

Reduction at first attempt

492  (96%)

 

 

RHS = radial head subluxation.

Mean age of patients = 29,52 months; median 26 months, range 2–146 months.


We organized the patients into six age groups. Group 1 from 0 to 12 month comprised 54 (10%), group 2 from 13-24 month 172 (34%), group 3 from 25-36 month 153 (30%), group 4 from 37-48 month 71 (14%), group 5 from 49- 60 month 37 (7%) and group 6 more than 60 month 25 (5%) patients (
Fig. 1). 

Figure 1: Number of patients in the different age groups

fig 1

Age groups 1 and 2 and 4 to 6 showed an equal relation between male and female patients. In age group 3 (25-36 month) there were significantly more girls involved: 102 girls versus 51 boys.

Children of the age group of 1-4 years made up for 396 cases (77,3%), 116 children (22,6%) were younger than 12 month and older than 48 month.

Causes of the condition were traction, unclear mechanism of injury, fall and twisting of the arm. Twisting of the arm was described as mechanism of injury if the condition had occurred without traction as a consequence of a free movement or turn over in babies. The numbers for every group are given in table 2. The predominance of the mechanisms of injury differed in all age groups (Fig. 2).

Table 2. Mechanism of injury

Age in Month

Group 1

0-12

Group 2

13-24

Group 3

25-36

Group 4

37-48

Group 5

49-60

Group 6

> 60

Group 1-6

0- >60

Traction

22 (41%)

103 (60%)

97 (63%)

44 (62%)

19 (51%)

13 (52%)

298 (58%)

Unclear

18 (33%)

  30 (17%)

32 (21%)

14 (20%)

  8 (22%)

  2  ( 8%)

104 (20%)

Fall

  6 (11%)

  31 (18%)

20 (13%)

12 (17%)

  9 (24%)

  6 (24%)

84 (17%)

Twisted

  8 (15%)

    8(5%)

  4 (3%)

  1(1%)

  1(3%)

  4 (16%)

26 (5%)

Total

54 (11%)

172 (33%)

153 (30%)

71 (14%)

37 (  7%)

25 (  5%)

512 (100%)

 

 

 

 

 

 

 

 

 

 

 

Figure 2: Different predominance of the mechanism of injury in concert with age

fig 2

Children with a history of fall had fallen from bunk beds, sofas, playground equipment, bicycle and swing. In boys fall was the mechanism of injury in 21 %, in girls a causative fall was found in 13%. There was a tendency in older children that falls occurred predominantly in boys with a male to female ratio of 5:1 in group 6 (Fig. 3).

Figure 3: Mechanism of injury in boys and girls

fig 3

Spontaneous reposition of the subluxation occurred in 51 cases (10%). Reduction was successful at first attempt in 492 patients (96 %). A history of RHS was documented in 55 cases (12%). All cases were unilateral.

X-rays were done in a total of 125 (24,4%) cases. In 88 (70,4%) of these cases an indication for radiography was made as there was a history of fall, in 17 ( 13,6%) because of an unclear history and in 20 (16%) cases x-rays were done after unsuccessful attempts at reduction.

In 20 cases (4%) repeated attempts at reduction were unsuccessful. X-rays were done and radiographic findings were normal in all these cases. The arm was than supported in a cast for four days and the child revaluated by a pediatric surgeon. In all cases return of function prompted at follow-up evaluation on day four without further attempts at reduction.

Discussion

To our knowledge this is one of the largest studies on pronatio dolorosa infantum published to date and the first to specifically examine the mechanism of injury in different age groups. We found that 58 % of children with RHS had a pull trauma as mechanism of injury. Fall accounted for 17 % of the injuries over all age groups but was more frequent in children aged 4 and more (24%). RHS occurred after twisting of the arm without traction as a consequence of a free movement or turn over in 15 % of children aged 0 to 12 months.

The medical literature indicates that the number of patients with RHS who are evaluated radiographically varies between 24% and 61% [3,4,8,17,18,19,22]. In our study, 24% of patients were radiologically examined, 70 % of those had a history of fall and 13,6% an unclear history.

Some investigators recommend that reduction of a suspected radial head subluxation without any prior radiological investigation should only be attempted when the typical history of an abrupt traction is positively reported [11]. Our data support that also in those cases with a clinical picture suggesting RHS where there are no clinical signs of fracture, even if there is an unclear mechanism of injury or a history of fall, reduction should be considered.

In some cases sonography may be helpful, but cannot be considered a routine diagnostic tool [4,9,10]. Similar to the study of Toupin [22] we have found that patients as young as 28 days and as old as 12 years can be diagnosed with RHS.

We found that a similar incidence of RHS was observed between group 1 aged between 13 and 24 months (33 %) and group 2 aged between 25 and 36 months (30%); children in these age groups made up for 63% of all cases.

The age groups 2 and 3 showed a somewhat homogenous profile and can be considered the so called typical cases. However, even in these patients a classic clinical history of pulling on the hand or wrist was only given in 62 % .

Fall was the mechanism of injury in 21 % of boys in all age groups with a tendency to occur more often in the older child. This fact has not been mentioned in the literature before. In another 20 % of all cases the parents were unsure as to what the cause of the injury was and could not describe the mechanism of injury.

In the very young age group of less than one year, twisting of the arm accounted for 15 % of the injuries, whereas in all other age groups only in 5 % of the children had a history of twisting. The youngest patient in our series, a 4 weeks newborn, had axial traction as the cause of injury.

Our data shows that common scenarios such as a toddler pulled by the hand or wrist are not the only cause which may lead to subluxation of the radial head. A history of fall or twisting of the arm, even an unclear mechanism of injury does not argue against RHS.

We believe that prevention is an important part of the management; therefore parents should be educated about the risk of reoccurrence. A history of RHS was positive in 12 % in our series though it has been reported to be as high as 24 % [21]. Furthermore parents should be motivated to tell the physician if the child has had this condition before [6, 7]. In our series this was important because a less experienced doctor will attempt reduction prior to radiography even with a history of fall if the child has had RHS before and protect the child from useless exposure to X-rays.

In our series if a child required reduction, only one attempt was needed in 96%; other studies have found that 77-84% of reductions are successful on the first attempt (5,13,14,17,18,20). Reduction is considered to carry a low risk if the indication for the manoeuvre is correct (7, 12) regardless which method of reduction is used.

Limitations

Owing to the retrospective methodology, the information extracted from the medical charts was limited by missing or incomplete data in some cases.

Conclusion

This study demonstrates that a history of a pull only accounts for 58 % of all cases with RHS. Fall accounted for 17 % of the injuries over all age groups and was more frequent in children aged 4 and more (24%). Reduction is easy and rapid.

 

 

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