Another in our recent orthopedic themed posts: a common toddler injury called “dislocated radial head.” I call it my favorite diagnosis, because here a child walks into my office sick (elbow pain) and walks out cured (pain resolved).
A quick anatomy lesson illustrates what happens and how this disorder received its common nickname. As illustrated, the forearm consists of 2 bones–the ulna (pinky side) and the radius (thumb side). The elbow end of the radius is shaped like a knob which allows that bone to rotate over the ulna at the elbow, allowing you to turn your palm down or up (pronate or supinate); a U shaped sling like ligament holds that knob end against the ulna so the radius can rotate and turn the palm over. In toddlers that ligament and the surrounding muscles are not as strong making the joint more injury prone.
That’s where the funny name from the title comes in: classically, the caregiver (nursemaid) gives a strong tug by the hand to the dawdling child to “keep up,” causing that knob end of the radius(at elbow) to get pulled under and past the U shaped ligament “dislocating” it. Basically any vigorous pull at the hand from a considerably stronger individual can cause it: pulling the child up from or to avoid a fall, too vigorous play/pulling arm by an older sibling.
The child will often cry out in pain and then hold the injured arm flexed 90 degrees at the elbow against their trunk. Any attempt to move the arm is very painful and will be strongly resisted. Noticeable swelling or discoloration at the joint is uncommon. The diagnosis is generally straightforward given the history of a pull at the child’s hand followed by pain and resistance against any movement thereafter. It’s usually pretty easy to fix with a simple maneuver in the office. (I encourage the “DIY”ers among you to leave that treatment to trained professionals–its your kid, not some kitchen appliance!) X rays aren’t required unless history isn’t clear, in which case, ruling out a fracture may be necessary. Curiously, it is not rare for the x ray tech to inadvertently reduce the injury while manipulating the arm to get optimal views for the radiologist. That’s ok, too.
After the dislocation is reduced, I frequently find that the child will continue to resist moving the elbow out of fear of more pain: I hold the uninjured arm and offer a lollipop; after a while they can’t resist, take the candy with the cured arm and realize that now it’s ok again. Follow up care is ice for swelling and ibuprofen for pain. Once the injury has occurred, the ligament is looser and more prone to re-injury. It is best to avoid pulling any young child hard by the hand, ever. In rare instances of multiple recurrences of this injury, orthopedic intervention to tighten the lax ligament can relieve that problem.
Please give me a call with questions and comments, and thanks for following. Featured image from: https://www.rch.org.au/clinicalguide/guideline_index/Pulled_elbow/