No longer a "nursemaid's" elbow: mechanisms, caregivers, and prevention.

OBJECTIVES: We sought to identify specific mechanisms leading to radial head subluxation, as well as correlation with different caregivers, as a potential platform for education and injury prevention.

METHODS: A retrospective cohort study of all patients admitted to an urban pediatric tertiary care emergency department with radial head subluxation from 1995 to 2009 was performed. Cases were identified using a text-search module followed by a manual chart review. We excluded patients with fractures, osteopenia, and neuromuscular conditions. Data collected included age, gender, arm involved, position of the arm at presentation, mechanism of injury, caregivers involved, imaging, and type of reduction. Multivariate logistic regression analysis was used to determine predictors for different mechanisms.

RESULTS: There were 3170 cases of radial head subluxation identified. The median age was 2.1 years (interquartile range, 1.5-2.8 years), and 59% were female (95% confidence interval [CI], 57%-60%). There were 2011 patients (63%) presenting with a traction mechanism, 547 (17%) with a nontraction traumatic mechanism, and 612 (19%) with an unknown or undocumented mechanism.Within the traction group, we identified several potentially preventable mechanisms including lifting the child by the arms (28.3%), "wrestling" (12.3%), swinging child by the arms (9.2%), and placing the child into and out of a seat (4.3%). Male caregivers were more likely to be involved when a child is swung by the arms (odds ratio [OR], 3.2; 95% CI, 1.6-6.2), lifted (OR, 1.9; 95% CI, 1.4-2.7), or "wrestled" with (OR, 6.4; 95% CI, 3.3-12.0). Mechanisms common for female caregivers included the child pulling away from parent (OR, 2.3; CI, 1.54 3.4), tripping (2.0; CI, 1.3-3.0), and getting dressed (OR, 2.1; CI, 1.1-4.4).

CONCLUSIONS: Radial head subluxation mechanisms can be classified into subcategories, which may be caregiver and even patient gender specific. Provider awareness regarding these mechanisms may help target education and prevention.