Radial head subluxation is more commonly known as nursemaid’s elbow. Because the radial head is not as bulbous in infants and young children, the annular ligament that passes around it can partially slip off the radial head with traction across the elbow (Fig. 203-1). The subluxation is usually caused by a quick pull on the extended elbow when a child is forcefully lifted by the hand or when the child falls while holding hands with an adult. After a subluxation, the child usually holds the hand in a pronated position and will refuse to use the hand or move the elbow. Moving the hand into the supinated position while applying pressure to the radial head will usually reduce the injury. Usually, radiographs are not necessary unless reduction cannot be obtained or there is concern for fracture (swelling and bruising). Once the injury is reduced, the child will begin using the arm again without complaint. Parents should be educated about the mechanism of injury and encouraged to avoid that position. There is a high rate of recurrence for this injury. The problem generally resolves with
Figure 203-1 Nursemaid’s elbow. The annular ligament is torn when the arm is pulled. The radial head moves distally, and when traction is discontinued, the ligament is carried into the joint. (From Rang M: Children’s Fractures, Philadelphia, 1974, JB Lippincott, p 121.) maturation, but some children with high recurrence rates may benefit from casting or, rarely, surgical intervention.
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Panner disease is an osteochondritis of the capitellum (lateral portion of distal humeral epiphysis) that occurs spontaneously in late childhood. Clinical features include elbow pain, decreased range of motion, and tenderness to palpation over the capitellum. Radiographs reveal fragmentation of the capitellum. Treatment is activity restriction and follow-up radiographs to demonstrate spontaneous reossification of the capitellum over several months. There is usually no need for further treatment or imaging studies. This is not to be confused with osteochondritis dissecans of the capitellum, which usually will occur in adolescents involved with throwing sports.
The elbow is especially vulnerable to throwing injuries in theskeletally immature athlete. These occur from excessive andrepetitive tension forces across the radial aspect of the elbow andcompression forces across the lateral aspect of the elbow. Theseinjuries are commonly known as Little Leaguer’s elbow.
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Although this injury is most common in baseball players who throw frequently (pitcher, catcher, third base, and shortstop), it also occurs in football quarterbacks and tennis players. Patients will usually complain of pain over the medial elbow with throwing that may last for a few days afterward. There may be associated swelling and lateral or posterior elbow pain. Radiation of pain may be secondary to ulnar neuropathy. There is often a flexion contracture of the elbow when compared to the opposite side. Palpation of the medial epicondyle, radial head, capitellum, lateral epicondyle, and olecranon process often reveals tenderness. Ulnar (medial) collateral ligament stability should be assessed. Radiographs should include the contralateral elbow for comparison. Radiographic findings in Little Leaguer’s elbow can vary and may include normal anatomy, medial humeral epicondyle apophyseal avulsion fracture, osteochondritis dissecans of the capitellum, radial head abnormalities, and foreign bodies in the elbow. MRI may be helpful.