CHAPTER

Annular Ligament
Displacement, Radial Head
Subluxation
(Nursemaid’s Elbow) 98
Presentation
A toddler who is between 1 and 4 years of age has received a sudden jerk on his arm, causing
enough pain that he holds it motionless against his body. Circumstances surrounding the
injury may be obvious (such as a parent pulling the child up by the arm to avoid stepping into a
puddle) or obscure (the babysitter who reports that the child “just fell down”). The patient and
family may not be accurate about localizing the injury and think that the child has injured his
shoulder or wrist. The patient is comfortable at rest, splinting his arm limply at the side with mild
flexion at the elbow and pronation of the forearm. There should be no deformity, crepitation,
swelling, or discoloration of the arm. There is also no palpable tenderness, except possibly over
the radiohumeral joint; the child will start to cry with any movement of the elbow, especially
attempted supination.

What To Do:
Rule out any history of significant trauma, such as a fall from a height.

Thoroughly examine the entire extremity, including the shoulder girdle, hand, and wrist. To
avoid obtaining a false-positive examination, special effort should be made to keep the elbow
joint perfectly immobile while evaluating for tenderness.

If there is significant trauma, point tenderness, swelling, ecchymosis, or any suspicion of a

fracture, get a radiograph.

When nursemaid’s elbow is suspected, place the patient in the parent’s lap and inform
the mother or father that it appears that a ligament in their child’s elbow is slightly out of place
and that you are going to put it back in place. Warn them that this is going to hurt for a few
moments.

Put your thumb over the head of the radius with your fingers supporting the elbow
and press down with your thumb while you smoothly and fully supinate the forearm and
extend the elbow. Complete the procedure by fully flexing the elbow while your thumb
remains pressing against the radial head and the forearm remains supinated (Figure 98-1).
At some point, you should feel a click beneath your thumb. The patient will usually scream for
a while at this point. Leave for about 10 minutes, then return and reexamine the elbow
to see that the child has fully recovered. This recovery may take as much as 30 minutes.
Postreduction immobilization is unnecessary.

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MINOR EMERGENCIES

Figure 98-1 Supination technique for annular ligament displacement (ALD) reduction.

Figure 98-2 “Handshake” or hyperpronation

maneuver. Simultaneous pronation of the
wrist and extension of the elbow (A), followed
by flexion of the elbow with the forearm
maintained in pronation (B). (Adapted from
Kaplan RE, Lillis KA: Recurrent nursemaid’s elbow
[annular ligament displacement] treatment via
telephone. Pediatrics 110:171-174, 2002.) A B

An alternative maneuver that some believe is more effective is the “handshake” or

hyperpronation maneuver. Grasp the hand of the patient’s affected arm as if to shake it,
place your other hand under the affected elbow with your thumb over the radial head, and
slowly pronate the wrist. This can be done alone or while simultaneously extending the
elbow, followed by fully flexing the elbow while still maintaining pronation of the forearm
(Figure 98-2).

Initial attempts at reduction using either technique are usually successful.

F ailure is more likely to occur if reduction is attempted 12 or more hours after the injury has
occurred.

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 CHAPTER 98  n  ANNULAR LIGAMENT DISPLACEMENT, RADIAL HEAD SUBLUXATION

If there is not full recovery, a repeated attempt using the alternative maneuver may
be warranted. If this is also unsuccessful, radiography should be obtained. Examine again
for possible injury to the clavicle or humerus (particularly the lateral condyle), and consider
other bone and joint disorders. Differential diagnosis includes fracture, soft tissue injury,
infection, arthritis, tumor, neurologic injury, and vasoocclusive crisis in sickle cell.

Place these children in a sling, with or without posterior splinting. (The elbow should be
kept at 90-degree flexion with as much supination of the forearm as comfort will allow.) Provide
pediatric or orthopedic follow-up within 24 to 48 hours. Self-reduction almost always occurs
during the period of immobilization.

When full recovery has been obtained, reassure the parents, explain the mechanism
involved in the injury, and teach them how to prevent and treat recurrences.

What Not To Do:

Do not attempt to reduce an elbow where the possibility exists of fracture or dislocation.

Do not get unnecessary radiographs when all the findings are consistent with nursemaid’s
elbow. The radiographs will appear normal.

Do not confuse nursemaid’s elbow with the more serious brachial plexus injury, which
occurs after much greater stress and results in a flaccid paralysis of the arm.

Discussion
Nursemaid’s elbow or annular ligament
displacement (ALD), formerly called radial head
subluxation (RHS), is a common pediatric orthopedic
problem. It is most often seen in children who are
between 1 and 4 years of age and is extremely rare
in children who are older than 5 years of age. This
displacement usually occurs as the result of a sudden
forceful longitudinal traction on the hand while the
forearm is pronated and the elbow is extended, as
when one pulls the forearm of a resisting child.
This condition is actually a displacement of the
annular ligament between the capitulum of the
distal humerus and the radial head. The annular
ligament is displaced from its normal position,
covering the radial head, into the radiohumeral
joint (Figure 98-3). Radiographs of an untreated
nursemaid’s elbow are normal without any evidence
of abnormal positioning of the radial head. Although
there is a transient subluxation of the radial head,
prolonged subluxation does not occur. ALD is more
common in girls and in the left arm. About one third
have had a previous episode.
The assessment of the young child is especially
challenging, because the child cannot relate a
coherent history, has difficulty localizing pain, and
often is frightened and uncooperative, hindering
physical examination. The classic history of a child
being pulled up by the arm while falling or lifted
by the arm is obtained in only 50% of patients.
The diagnosis is nonetheless made by history and
physical examination and confirmed by prompt
reuse of the affected arm following reduction.
Supination or pronation of the forearm usually
causes reduction of the annular ligament back into
its normal position. The reported recurrence rate
involving either the same or contralateral arm is
extremely variable, ranging from 5% to 39%.
ALD should be considered in any toddler presenting
with arm injury without obvious evidence of trauma.
The key to diagnosis is the observation that the
child is not in pain; has no swelling, ecchymosis, or
deformity; holds the elbow in a slightly flexed position
with wrist pronated; refuses to use the arm; and resists
supination. When history and physical examination
suggest ALD, it is appropriate to attempt reduction
without obtaining radiographs. Successful reduction
is more likely when a click is felt. On occasion, if the
(continued)

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MINOR EMERGENCIES

Discussion continued
injury has been present for several hours, edema, child by placing her in a second adult’s lap and then
pain, and natural splinting will continue even after have him grasp the child’s hand. With the treating
reduction or may prevent reduction. adult’s other hand under the child’s affected elbow,
straighten out the arm with the palm of the child’s
Although not fully proven safe, parents or
hand facing upward. Then, have the child bend the
caretakers can be instructed by telephone to treat
elbow up, touching the palm of her hand to the
ALD, especially in those cases in which there is a
same shoulder. After 20 minutes, the child should be
previous history and in which the history is typical of
moving the arm normally.
recurrent ALD. Instruct the caregiver to restrain the

Annular
ligament

Figure 98-3 Annular ligament displacement (nursemaid’s elbow). (Adapted from Kaplan RE, Lillis KA: Recurrent nursemaid’s elbow [annular ligament
displacement] treatment via telephone. Pediatrics 110:171-174, 2002.)

Suggested Readings

Frumkin K: Nursemaid’s elbow: a radiographic demonstration, Ann Emerg Med 14:690–693, 1985.
Meiner EM, Sama AE, Lee DC: Bilateral nursemaid’s elbow, Am J Emerg Med 22:502–503, 2004.
Quan L, Marcuse EK: The epidemiology and treatment of radial head subluxation, Am J Dis Child 139:1194–1197, 1985.
Schunk JE: Radial head subluxation: epidemiology and treatment of 87 episodes, Ann Emerg Med 19:1019–1023, 1990.
Schutzman SA, Teach S: Upper-extremity impairment in young children, Ann Emerg Med 26:474–479, 1995.

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