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BMJ Case Rep. 2010; 2010: bcr10.2009.2360.
Published online Mar 4, 2010. doi:  10.1136/bcr.10.2009.2360
PMCID: PMC3029135
Unusual presentation of more common disease/injury
Radial head subluxation in an 8-year-old girl with joint hypermobility
Marc Alan Barton
Kingston Hospital NHS Trust, Emergency Medicine, Galsworthy Road, Kingston upon Thames KT2 7QB, UK
Correspondence to Marc Alan Barton, marc_barton/at/hotmail.com
An 8-year-old girl attended the children’s emergency department after having been play-fighting with her younger brother. Her arm had been pushed away by her father during the fight. The girl immediately complained of pain in her arm and refused to move it. Following analgesia and investigation with a plain radiograph of the elbow it was decided to attempt a manipulation procedure with the possibility that this could represent a ‘pulled elbow’ in an unusual age group. Soon after the manipulation the child was completely pain-free and moving her arm fully at the elbow, suggesting a diagnosis of radial head subluxation. The patient demonstrated hypermobility of several joints and she was able to hyperextend her unaffected elbow by >10°. This case highlights the association between radial head subluxation and joint hypermobility.
Radial head subluxation, more commonly known as ‘pulled elbow’ or ‘Nursemaid’s elbow’, is a common condition that frequently presents to paediatric emergency departments. It has a reported annual incidence of 1.2% in children between the ages of 5 months and 5½ years of age.1 The age range at presentation is classically described as being between 1 and 3 with the mean age being just older than 2 years, and the condition being rare over the age of 5.2 It is more common in females and is most frequently seen in the left arm which is thought to be because most care givers are right handed.3 It is caused by a slip of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than adults and allows it to be more easily torn. The ligament strengthens with age making subluxation less common. It has been demonstrated that there is an association between joint hypermobility and radial head subluxation.4
An 8-year-old girl attended the children’s emergency department after having been play-fighting with her younger brother. During an attempt to poke her brother in the eye her father tried to deflect the blow by pushing her arm away. Her father described the mechanism as a downwards push on the volar aspect of her forearm and in doing so applied longitudinal traction to the elbow. The girl immediately complained of pain in her arm and refused to move it. On arrival she was noted to be holding her arm in a flexed and pronated position. She had no history of prior injuries to the elbow and no previous history of radial head subluxation, but of note both her mother and brother had been diagnosed as having joint hypermobility. Her parents felt that she may also have hypermobile joints. On examination she was unable to actively move the arm and there was diffuse tenderness around the elbow and upper forearm. No neurovascular deficit was demonstrated.
Investigations
In view of her age and the history, a radiograph of the elbow was requested which revealed only a small non-raised anterior fat pad (fig 1).
Figure 1
Figure 1
Elbow radiograph on presentation.
Treatment
Despite analgesia the girl still refused to move her arm and it was decided to attempt a manipulation procedure with the possibility that this could represent a ‘pulled elbow’ in an older age group. The forearm was gently pronated and a palpable ‘click’ was felt during the manoeuvre. Within 5 min of the manipulation the child was completely pain-free and moving her arm fully at the elbow, making radial head subluxation the most likely diagnosis.
Outcome and follow-up
After the procedure a hypermobility assessment was carried out. The patient demonstrated hypermobility of several joints and she was able to hyperextend her unaffected elbow by >10°. It was agreed that she should be followed up by her general practitioner and have a formal assessment for joint hypermobility organised.
The diagnosis of radial head subluxation is a clinical diagnosis made on the basis of a compatible history and examination with a good response to manipulation. Due to the unusual age and mechanism of injury there is the possibility that the presentation was related to simple soft tissue injury. However, in light of the family history and the rapid resolution of symptoms following the manipulation, the likelihood of radial head subluxation being the underlying cause is high.
Hypermobility occurs in 5% of the population and children tend to have a greater range of joint movement than adults.5 Connective tissue disorders causing hypermobility such as Marfan and Ehlers Danlos syndromes are well known to have an association with joint dislocations including elbow, temporomandibular joint, patellae, fingers and hip dislocation.6 Benign joint hypermobility syndrome (BJHS) is described as the occurrence of musculoskeletal symptoms in hypermobile individuals in the absence of systemic rheumatologic disease.7 BJHS has been associated with a wide variety of musculoskeletal disorders in childhood, ranging from ‘growing pains’ to more serious problems such as chronic back pain and even spondylolysis.5 It is also associated with joint subluxation and dislocation. If detected early BJHS can be managed with advice, physiotherapy and occupational therapy input which are likely to improve the outcome.
BJHS can be diagnosed using the Brighton scoring system8 which is based on a series of major and minor criteria including arthralgia, recurrent subluxation or dislocation of joints. Alternatively a Beighton score9 is a simple assessment which is based on a sequence of manoeuvres assessing joint flexibility and is scored out of nine. A first degree relative who is unequivocally affected is also a determining factor. BJHS is excluded in the presence of Marfan or Ehlers-Danlos syndromes.
Although radial head subluxation has been reported in an adolescent9 and on two occasions in adults,10,11 the age range is usually stated as being between 1 and 3 years. In one study3 of 100 patients only three children with radial head subluxation were over 5 years of age and none were over 6. It can therefore be argued that in older individuals with radial head subluxation a predisposing pathology such as BJHS should be considered.
Learning points
  • Radial head subluxation, although rare in patients over the age of 5, should be considered in those with a compatible history and examination.
  • If an older child is diagnosed with radial head subluxation, an underlying diagnosis of hypermobility or benign joint hypermobility syndrome (BJHS) should be considered.
  • Early detection and appropriate management of these conditions is likely to improve the patient’s long term outcome.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
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9. O’Neill BJ, Hirpara KM, Devitt AT, et al. Irreducible pulled elbow in an adolescent. A case report. Eur J Trauma Emerg Surg 2009; 35: 79–80.
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11. Pearson B, Kuhns D. Nursemaid’s elbow in a 31-year-old female. Am J Emerg Med 2007; 25: 222–3. [PubMed]
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