Radial Head Dislocation

Definition

  • Also called nursemaid’s elbow or radial head subluxation
  • Annular ligament slips proximally over the radial head into the radiocapitellar joint
  • Soft tissue subluxation, the radial head does not truly dislocate

Epidemiology

  • Commonest elbow injury in young children
  • Ages 1 to 4 years, peak 2 to 3 years
  • More common in girls and on the left
  • Recurrence common until about 5 years, when the radial head enlarges and ligament strengthens

Aetiology

  • Sudden longitudinal pull on the extended, pronated arm, such as lifting or swinging by the hand
  • No clear pull history in some cases, especially infants

Clinical Features

  • Child refuses to use the arm, held by the side with elbow slightly flexed and forearm pronated
  • Pain on attempted supination with radial head tenderness

Investigations

Radial Head Dislocation, radiograph of a congenital radial head dislocation
Radiograph of a congenital radial head dislocation. Image by Hellerhoff, Wikimedia Commons, CC BY-SA 3.0.
  • No radiographs needed with a consistent history and examination
  • X-ray for swelling, bruising, a fall, direct trauma or tenderness away from the radial head
  • X-ray if the arm is not used after reduction
  • Radiographs of a pulled elbow are normal

Management

  • Supination then full flexion, with the thumb over the radial head
  • Hyperpronation with the elbow flexed is at least as successful and may hurt less
  • A palpable click over the radial head confirms reduction
  • Most children use the arm within 10 to 15 minutes
  • Persistent non-use needs radiographs to exclude fracture
  • Advise parents against lifting or swinging the child by the hand

Differential Diagnosis

  • Isolated radial head dislocation is a Monteggia lesion until proven otherwise
  • Radial neck and shaft line passes through the capitellum on every view
  • A missed Monteggia lesion becomes a chronic dislocation, much harder to treat
  • Congenital dislocation is posterior or posterolateral, often bilateral and painless, linked to nail patella syndrome
  • Congenital form has a dome-shaped radial head, hypoplastic capitellum and long radius
  • Congenital form is irreducible, left alone, with radial head excision at maturity for pain
  • Supracondylar, lateral condyle, radial neck and clavicle fractures, and septic arthritis

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.