Subluxation of the radial head in children under three years of age is a fairly common occurrence, and it occurs twice as often in girls as in boys. Older children of preschool age are also at risk, but after six years such injury is already rare. The fact is that in children of this age, the head of the radius is a rounded cartilaginous tissue, and even with a slight sudden movement it can freely slip out of the annular ligament. Most often, injuries occur if a child is pulled by the arm while playing, or if he was walking with an adult by the hand, tripped and fell, and the adult tried to support him and pulled his arm. Less commonly, such an injury occurs when a child falls under his or her arm. And sometimes such stretching of the arm occurs when, while playing, a child is taken by both hands and rotated around himself, and even when putting on and taking off clothes with narrow sleeves. In some cases, at the moment of dislocation, you can hear a characteristic crunch. Parents of preschoolers may encounter this problem more than once, but fortunately, once they leave preschool age, the likelihood of such an injury is practically reduced to zero.
What to do if a subluxation of the radius occurs
If such an injury occurs, you should immediately contact a children's emergency room or a children's hospital. The sooner you ask for help, the easier it will be to provide. By the way, the emergency room of the EMS clinic is open 24 hours a day. Most often, apart from examination and history taking, no additional diagnostic methods are required. If the diagnosis is confirmed, an experienced traumatologist or surgeon will be able to straighten the injured arm without delay. This procedure does not require pain relief; parents just need to distract the child so that he is less nervous. At the moment of reduction, pain will occur, which will go away almost immediately, and the child will feel relief. After a while he will completely forget about the problem with his hand.
After successful reduction, it is recommended to wear the sore arm in a fixed position for a couple of days on a soft bandage or scarf tied over the shoulder.
Important!
- You need to remove clothes (jacket, sweater) first from the healthy arm, and then from the sick one.
- Put the jacket/jacket on the other way around: first on the sore arm, then on the healthy arm
- It is advisable not to move the child’s hand
Publications in the media
Frequency. Forearm dislocations rank 2nd (18–27%) among all dislocations. 90% of cases are dislocation of both forearm bones and anterior dislocation of the radius.
Cause: injury - falling on an outstretched arm while hyperextending the elbow joint.
Classification • Dislocation of both bones of the forearm (anterior, posterior, outward, inward, divergent dislocation) • Dislocation of the radius (anterior, posterior, outward) • Dislocation of the ulna.
Clinical picture. Posterior dislocation of the forearm is described • Pain • Forced position - semi-extended state • Active movements are impossible • Increase in the volume of the joint area • Symptom of spring fixation • Shortening of the forearm when viewed from the front • The olecranon protrudes posteriorly, is located above and posterior to the Huether line - the line connecting the epicondyles • The epiphysis of the humerus is palpated in the elbow bend.
Treatment
• Posterior dislocation of the forearm •• Anesthesia or local anesthesia •• Reduction. The patient lies on his back, the arm is abducted at the shoulder and bent at the elbow joint at an angle of 90°. They clasp the shoulder with both hands and press the olecranon with their thumbs. At the same time, the assistant pulls the forearm along its length and bends it at the elbow joint •• Immobilization with a plaster splint (on the back surface) for 1 week •• Exercise therapy from the first day, physiotherapy.
• Anterior dislocation of the forearm •• The assistant pulls the forearm along its length, slowly bending it at the elbow joint. The surgeon presses with his thumbs on the articular end of the humerus, while simultaneously moving the forearm proximally. After reduction, the forearm is extended and the limb is fixed with a plaster splint for 7–10 days in the supination position •• If conservative reduction is ineffective, surgical treatment is used •• If ossification occurs (after 2 weeks), phonophoresis with hydrocortisone, electrophoresis with lidase is prescribed, ossifications are removed, arthrodesis is used or elbow arthroplasty.
Features in children • 1st place among all dislocations in children • Fracture-dislocation is often observed in children - Galeazzi, Monteggia fractures, subluxation of the head of the radial bone • With external dislocation of the forearm bones, in 50% there is a separation of the apophysis of the internal epicondyle of the humerus • Reduction of uncomplicated dislocation is carried out without flexion or forearm extension.
Subluxation of the radial head. Causes: indirect injury, traction on the forearm, trying to hold the child’s hand when he falls, wearing clothes with narrow sleeves. The predominant age is 1–3 years; it is not observed in children over 5 years of age.
Pathomorphology: displacement of the head of the radius in relation to the capitate eminence of the humerus in the annular ligament and entrapment of the synovial fold of the joint. Clinical picture: the forearm is bent, pronated, the arm hangs along the body (pseudoparalysis); the child cannot localize the pain; on palpation - the greatest pain is in the area of the head of the radial bone; there is no active movement in the elbow joint, often movement is limited in the shoulder joint; passive movements: flexion and extension are painless, severe pain when rotating the forearm; X-ray examination reveals an increase in the distance between the head of the radius and the capitate eminence of the humerus. Treatment • Grab the wrist with one hand, and the elbow joint with the other hand (the surgeon’s first finger should be above the dislocated head of the radius). The forearm is pulled along the axis, then supinated and flexed to a right angle at the elbow joint with simultaneous pressure on the head of the radius. Reduction occurs during flexion with a characteristic click - the child calms down, active movements are restored. • After reduction, it is recommended to immobilize the arm with a scarf for 1-2 days. ICD-10. S53.0 Dislocation of the radial head
ICD-10 • S53.0 Dislocation of the radial head • S53.1 Dislocation of the elbow joint, unspecified
Causes of the disease
This may be a congenital subluxation in children, fractures of the hip joints, or a case of sudden movements. For example, the child’s hand is extended and calmly lies in the mother’s hand. Any danger or obstacle causes the mother to unintentionally grab the child and pull or even carry her by one arm in the area of the hand or wrist joint. Often such situations arise in children simply while playing.
Sometimes parents may hear a crunching sound, which should be a sign of concern. In this situation, a sharp pull of the arm occurs along the longitudinal axis and the head slips out of the joint ligament. The founder of pediatric surgery, Ternovsky, called this phenomenon the anatomical features of the musculoskeletal system in children under three years of age.
As the child grows, this phenomenon disappears and damage of this nature becomes uncharacteristic. No independent actions can be carried out, because a fracture of fragile bones is not excluded.
Falls lead to fractures of the ankle, hip or shoulder joints. If all this can be quickly corrected between the ages of one and four, then it is at this age that children are most susceptible to injury.
Symptoms
Whatever the clinical situation, subluxation of the wrist or shoulder joint causes pain in the baby, and he screams.
After this, he cannot move his arm; it is extended along the body, the elbow joint is slightly bent. It is impossible to force a child to make a movement. He becomes indignant and complains of pain, pointing to the elbow joint or wrist.
The child also experiences pain upon palpation. An X-ray examination is useless in this case, since the pathology will not be detected in the image. The structure of the head of the wrist joint in children under five years of age consists mainly of cartilaginous tissue. And if the child raises his hand more than 25 degrees, then the head may simply slip out. The worst thing is that ligaments that do not yet have sufficient strength may rupture.
Other types of subluxations
The most common type of subluxation is ulnar. Despite the fact that any subluxations are classified according to ICD -10 - S53.0, there are other types.
Congenital subluxation of the shoulder joint. Usually it occurs after a pathological birth, when the child has to be pulled by the arms or legs, then this already belongs to the category of femoral subluxation or an ulnar subluxation is diagnosed. It is usually diagnosed immediately after birth and treatment ends with reduction right in the delivery room.
Among all the “abundance” of subluxations, subluxation of the hip joints is no less rare. It can also be congenital. Or acquired by all the methods described. Children should not be pulled by their arms or legs. But most femoral subluxations are congenital.
Femoral subluxation occurs more often due to the fact that the femoral joint is underdeveloped, morphological changes have occurred, and the femoral joint has a displaced head.
Subluxation of the ankle. It can be congenital or acquired. Ankle subluxation occurs as rarely as any other.
Parents need to focus their attention on ankle subluxation.
And not only because the disease is childhood or it is a congenital dislocation. This is a disease that often affects adults. Overweight people place heavy stress on their ankle joints. Minor pain and an untreated fracture lead to the disease becoming inveterate. Then the treatment is longer and more complex.
Sooner or later, the disease will still make itself felt. Ankles often suffer even due to the fact that a person stands up abruptly or the legs are simply in the wrong position; high heels and uncomfortable shoes also lead to ankle subluxation.
Diagnostics
As mentioned above, diagnosis can only occur through palpation or MRI examinations. An x-ray will not show this injury. But in some cases, the doctor prescribes an x-ray examination. This happens in the following cases:
- with joint deformation;
- when there is swelling or hematoma;
- if you suspect a fracture of the wrist or shoulder joint;
- if manual reduction fails.
Treatment
The first thing the doctor will try to do when confirming the diagnosis is reduction using the closed method. This is a completely painless procedure. But the baby experienced discomfort and pain before this, so it is necessary to divert his attention.
First of all, the doctor moves the shoulder joint slightly to the side and fixes it. Then he takes the baby by the hand and holds his hand in the area of the wrist joint. Then he turns his hand a little until a click is heard.
Important! In no case should you try to realign the wrist joint, as well as the elbow and shoulder joints. Such independence can lead to rupture of connective tissues, and treatment will be protracted and painful.
Treatment carried out by a pediatric orthopedist usually ends successfully and, even before leaving the office, the child forgets about the pain that recently bothered him. Usually this disease has no consequences, but it is necessary to carry out preventive examinations and perform simple physical therapy exercises. After treatment has been completed, the doctor must give recommendations to parents on further actions.
Treatment
It is important to begin treatment immediately after an injury in order to recover faster. A medical professional should realign the joint. The faster this happens, the easier it will be to prevent complications and get rid of unpleasant symptoms.
You can proceed to therapy immediately after the x-ray. In some cases, a medical specialist may order an ultrasound or arteriogram if it is necessary to check the nerves and blood vessels for damage. A consultation with a neurologist may be required.
Conservative therapy includes the following steps. First, the doctor numbs the injury site, then performs a reduction. For a posterior dislocation, the elbow must be bent even more, or the joint must be extended and then bent. For the front one, you will need to bend your arm and move the joint back. If everything is done correctly, a click will appear.
Then the doctor applies a tight bandage, and in some cases insists on a plaster cast. When the injury is open, a splint is required.
It is advisable that the reduction occur within the first hour after the injury. Then there should be no complications.
Treatment and restoration of elbow dislocation in some cases requires surgery. This is indicated when the injury is severe, nerves, blood vessels, and ligaments are damaged. In addition, surgery is prescribed if a lot of time has passed since the dislocation and it can no longer be corrected in any other way.
If the injury occurred a month ago, even surgery cannot always help fully restore the function of the joint. The recovery period in this situation will take much longer.
Elbow subluxation can often occur in children. The joint structure of children is different in structure, so ordinary dislocation is rare.
Subluxation is difficult to diagnose immediately after its appearance. If the doctor prescribes the wrong therapy, then the problem may remain for life. Subluxation can even occur when a child is accidentally pulled or tugged on the arm. Damage can be suspected by a characteristic cracking or clicking sound, if there is severe pain. If the mobility of the arm is limited, swelling is observed, then subluxation can also be assumed.
The doctor must realign the joint, after which the unpleasant symptoms will gradually disappear. It is worth noting that at the age of 5 years such an injury rarely occurs.
Prevention
After treating any type of subluxation, your doctor may recommend preventative measures. If children have ulnar or femoral subluxation, they need to be set. An ankle fracture is treated quite simply. With the exception of the hip joints. Such diseases often force the child to wear special stirrups, which remain on the child for quite a long time.
Shoulder, elbow, congenital, and chronic subluxations in children are easier to treat. It is enough to straighten them, and then follow the doctor’s recommendations and include physical therapy exercises in your daily routine. In children, all joints are not yet ossified; they consist mainly of cartilage, so treating them is not so difficult. Unless, of course, we are talking about femoral subluxation (ICD-10).
In adults, treatment is much more serious and complicated. If a child is diagnosed with congenital subluxation or the subluxation occurred in the first four years, then it is possible to correct it. Further, when the joints develop and become stronger, it is more difficult to treat. Sometimes they may even suggest replacing a joint with an implant.
It is equally important to create the right diet. This is a food rich in calcium and collagen. No bad habits in adults, active lifestyle.
Causes
Dislocation is common, and it can be of different types: primary, secondary and habitual. The last of them usually affects the hip and shoulder joints, which is explained by the peculiarities of their structure. The elbow joint is a complex joint in terms of physiology. It is the articulation of three bones: the radius, ulna and humerus. They form two joints, which are enclosed in one capsule. Both have limited mobility but perform important tasks.
Near the humeroulnar and radiobrachial joints there are nerves and great great vessels. For this reason, violation of anatomical integrity can lead to dangerous complications.
A joint is a movable connection of skeletal bones. It has elastic properties, so it softens the shock. The area is considered strong, so there is a chance of injury only in case of strong impact. Recovery time depends on how severe the injury is.
Common causes of dislocation are a fall on an outstretched arm, an accident, blows and jerks. In some cases, injury may occur due to concomitant pathology. We are talking about arthritis or arthrosis. Then the dislocation will be called pathological.
Regardless of the reason, it is necessary to undergo rehabilitation. Recovery from an elbow dislocation takes time, but without it complications can arise.
Radius fracture
Fractures of the head and neck
A fracture of the radius in the head region usually occurs as a result of a fall on an outstretched and slightly abducted arm.
Accounts for about 20% of the total number of injuries to the elbow joint. In 50% of cases it is combined with damage to other anatomical structures, in 10% of cases – with dislocation of the bones of the forearm. It manifests itself as pain and swelling in the elbow area. The pain intensifies with palpation, trying to turn or bend the arm. Crepitation is not detected. To clarify the diagnosis, an x-ray of the elbow joint is prescribed. Treatment is usually conservative. For injuries without displacement, a plaster cast is applied; if there is displacement, closed reduction is performed, and then control photographs are taken. If the result of the control radiography is unsatisfactory, repeated reduction is carried out with fixation of the head with a pin. Then a plaster cast is applied, the wire is removed after 2-3 weeks, immobilization is continued for 4-5 weeks. In case of multi-fragmented injuries and significant destruction of the head, surgical intervention is indicated - resection of the head or endoprosthetics of the head using a silicone prosthesis. The latter method is usually used when treating young patients.
Isolated shaft fractures
A fracture of the radius in the diaphysis area occurs as a result of a blow to the radial side of the forearm and is observed quite rarely. Symptoms are usually erased. Swelling occurs in the area of damage, patients complain of pain that increases with palpation and movements, especially rotational ones. Crepitation and pathological mobility are usually absent, since the radial bone fragments are supported by the entire ulna and interosseous membrane. The diagnosis is confirmed using radiography of the bones of the forearm.
For damage without displacement, a plaster cast is applied for 8-10 weeks. If there is displacement, closed reduction followed by immobilization for 8-12 weeks is indicated. If the fragments cannot be compared (usually happens when soft tissue is inserted between bone fragments), surgical intervention is necessary - osteosynthesis of the radius with a plate or pin.
MRI of the elbow joint. Fracture of the head of the radius with slight displacement of fragments.
Damage to Galeazzi
Described by the Italian surgeon Galeazzi in the first half of the twentieth century. It is a combination of a fracture of the radius and dislocation of the ulna at the wrist joint. Such injuries account for about 7% of the total number of fractures of the forearm bones and are formed when falling on a pronated hand. Accompanied by pain in the lower and middle third of the forearm, severe swelling and the formation of subcutaneous hematomas. Movement in the wrist joint is limited.
Distinctive features of this injury are frequent concomitant nerve damage, the development of compartment syndrome (compression of nerves, veins and arteries by edematous soft tissues) and the need for surgical intervention to restore normal anatomical relationships of the forearm bones. Signs that suggest nerve damage are loss of sensation and movement in the hand area. Increasing tension of the soft tissues, excruciating increasing pain and increased pain when pulling on the fingers indicate the presence of compartment syndrome.
The diagnosis is made on the basis of an x-ray of the forearm involving the wrist joint. In doubtful cases, comparative radiographs of both forearms are performed or a bone CT scan is prescribed. If nerve injury or vascular damage is suspected, consultations with a vascular surgeon and neurologist are prescribed. For compartment syndrome, immediate fasciotomy is necessary. Surgical treatment – open reposition and osteosynthesis of the radius with a plate. If necessary, the head of the ulna is additionally fixed with a pin. Immobilization is continued for 6-8 weeks, then rehabilitation measures are prescribed, including exercise therapy, massage and physiotherapy. For old injuries, distraction devices are applied.
Fracture in a typical location
Fractures of the radius in a typical location (just above the wrist joint) are the most common fractures of the forearm bones. Often observed in children and young people, however, they are most often found in the elderly, due to osteoporosis. As a rule, they occur during a fall with support on an outstretched arm, and may or may not be accompanied by displacement of fragments. Taking into account the nature of the displacement, two types of such injuries are distinguished - Colles fractures and Smith fractures. With a Colles fracture, the distal fragment is displaced to the rear, with a Smith fracture - to the palm. In addition, such fractures can be intra-articular or extra-articular, open or closed.
The damage is accompanied by severe pain, swelling and hemorrhage. Crepitation and pathological mobility are possible. When displaced, a visible deformation is revealed just above the joint or in its projection. Movement and palpation are sharply painful. The diagnosis is confirmed by the results of radiography of the wrist joint. For complex fractures and during preoperative preparation, CT of the wrist joint and MRI may be required. Treatment in the vast majority of cases is conservative.
X-ray of the wrist joint. Fracture of the distal metaepiphysis of the radius with displacement of fragments.
For fractures of the radius without displacement, a plaster cast is applied; for displacement, after performing a blockade, closed reduction is performed, followed by the application of a simple or plastic plaster cast. If necessary, percutaneous fixation with knitting needles is used to better retain the fragments. Then the patient is sent for a control x-ray. If the fragments are in satisfactory condition, the plaster is preserved for 4-5 weeks. If reposition fails, re-reduction is attempted. If the fragments could not be matched, surgery is indicated.
Surgery is performed in a hospital setting. Osteosynthesis of the distal metaepiphysis of the radius with a plate or screws is possible. In case of complex open fractures, the application of metal structures in the wound area is contraindicated, therefore, in such cases, external fixation devices are used. In the postoperative period, UHF, painkillers and antibiotics are prescribed. The timing of the start of rehabilitation measures depends on the type of osteosynthesis. Stable fixation with a plate allows you to begin physical therapy within a week after surgery; with other treatment methods, the development of the joint is postponed to a later date.