42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

ABFM Family Medicine Certification Study Guide Exam

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23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

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25 Chapter 25: Hematologic, Urologic & Dental Emergencies

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26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

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28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

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29 Chapter 29: Acute Upper Respiratory Tract Infections

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33 Chapter 33: Acute Upper Gastrointestinal Conditions

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35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

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36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

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37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

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38 Chapter 38: Acute Infectious Dermatoses

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39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

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40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

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41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

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45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

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46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

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47 Chapter 47: Acute Women's Health & Early Pregnancy Care

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48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

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49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

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50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

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52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

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53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

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55 Chapter 55: Chronic Endocrine Disorders

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56 Chapter 56: Chronic Kidney Disease & Venous Disorders

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57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

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58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

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61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

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62 Chapter 62: Chronic Psychiatric Disorders

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63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

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64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

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65 Chapter 65: Chronic Dermatologic Conditions

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66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

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67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

Key Takeaways Explain This Topic AI

Radial head subluxation ('nursemaid's elbow') is the most common pediatric elbow injury (peak incidence ages 1-4 years), caused by sudden longitudinal axial traction on an extended, pronated arm that pulls the radial head beneath a lax annular ligament, entrapping it in the radiohumeral joint.

Children with classic nursemaid's elbow hold the arm slightly flexed and pronated against the trunk and refuse to use it ('pseudoparalysis') without swelling, ecchymosis, or bony deformity; plain radiographs are unnecessary in typical cases and should be reserved for atypical histories, trauma, or failed reductions.

Hyperpronation demonstrates a superior first-attempt reduction success rate (85%-95%) compared to the traditional supination-flexion technique (70%-75%) for nursemaid's elbow; a palpable click confirms reduction, and successful resolution is evidenced by spontaneous use of the arm within 10 to 15 minutes.

Anterior glenohumeral dislocations represent >95% of shoulder dislocations and present with a 'squared-off' shoulder and flattened deltoid; pre- and post-reduction evaluation must rigorously test axillary nerve sensory integrity over the lateral deltoid 'regimental badge' patch.

Posterior glenohumeral dislocations (2%-4%) are classically triggered by epileptic seizures, electrical shocks, or lightning strikes, locking the arm in fixed adduction and internal rotation; standard AP radiographs often show only the subtle 'lightbulb sign', making the axillary lateral or scapular Y view mandatory for diagnosis.

Last updated: September 2026

Radial Head Subluxation ("Nursemaid's Elbow")

Radial head subluxation—colloquially known as "nursemaid's elbow" or "pulled elbow"—is the most frequent upper extremity injury presenting in toddlers and preschool-aged children. Peak incidence occurs between 1 and 4 years of age , with a slight predilection for females and the left arm (typically the arm held by an adult holding the child's hand). NURSEMAID'S ELBOW PATHOANATOMY

• 1. Longitudinal Axial Traction on Extended & Pronated Arm
• │
• ▼
• 2. Small, Cartilaginous Radial Head Slips Distally Beneath Annular Ligament
• │
• ▼
• 3. Annular Ligament Slips Over Radial Head into Radiohumeral Joint
• │
• ▼
• 4. Ligament Becomes Entrapped Between Radial Head & Capitellum
• ──► Toddler holds arm flexed & pronated; refuses movement
• Pathophysiology

In children under 5 years of age, the annular ligament is relatively thin, pliable, and loosely attached to the radial neck. Furthermore, the pediatric radial head is predominantly cartilaginous, pliable, and lacks the prominent osseous flare of the mature adult radial head. When sudden longitudinal axial traction is applied to an extended and pronated forearm (e.g., an adult pulling a toddler by the hand to prevent a stumble, lifting a child onto a curb, or swinging a child playfully by the wrists), the radial head is pulled distally beneath the annular ligament. As traction is released, the proximal margin of the annular ligament curls over the radial head and becomes entrapped within the radiohumeral joint space , wedged between the radial head and the humeral capitellum.

Clinical Presentation & When to Avoid Radiographs

Classic Presentation : The child cries immediately following the traction event, but rapidly settles into a quiet, protective state. The child presents holding the injured extremity splinted closely against the abdomen or lap, with the elbow held in slight flexion (20° to 30°) and pronation . The child adamantly refuses to move or use the arm—a presentation termed "pseudoparalysis" .

Physical Examination Findings : There is a striking absence of inflammatory or traumatic signs : NO localized edema, NO ecchymosis, NO warmth, and NO visible deformity. Palpation of the clavicle, acromion, humerus, olecranon, forearm, and wrist elicits no distress. Minimal, mild discomfort may be localized over the anterolateral radial head. Forearm supination is resisted.

Radiographic Indications : Radiographs are completely normal in nursemaid's elbow because the displaced annular ligament is radiolucent. Plain radiographs are NOT required in classic presentations !

Radiographs are indicated ONLY when: (1) The mechanism of injury involves significant direct blunt trauma, a fall from a height, or suspected non-accidental trauma/abuse; (2) Focal bony point tenderness, significant edema, or deformity is identified on exam; or (3) The child fails to resume normal active arm use after 2 to 3 technically successful reduction attempts.

Closed Reduction Techniques: Hyperpronation vs. Supination-Flexion

Closed reduction is performed immediately at the bedside without sedation or analgesia: NURSEMAID'S REDUCTION MANEUVERS

• HYPERPRONATION TECHNIQUE SUPINATION-FLEXION TECHNIQUE
• (Higher 1st-Attempt Success: 85-95%) (Traditional Technique: 70-75%)
• ───────────────────────────────────── ─────────────────────────────────
• 1. Examiner thumb over radial head 1. Examiner thumb over radial head
• 2. Support flexed elbow at 90° 2. Apply slight axial traction
• 3. Firmly HYPERPRONATE forearm 3. Fully SUPINATE forearm
• 4. Palpable "click" felt at radial head 4. Fully FLEX elbow toward shoulder
• 5. Child reaches for toy in 10-15 min 5. Palpable "click" felt at radial head

The Hyperpronation Technique :

Method : The clinician supports the child's elbow at 90° of flexion with one hand, placing the examiner's thumb directly over the anterolateral radial head. With the other hand, grasp the child's distal forearm and wrist, apply slight axial compression, and firmly and smoothly hyperpronate the forearm (rotating the palm downward past full pronation).

Endpoint : A subtle but distinct palpable "click" or snap is felt under the examiner's thumb as the annular ligament slides out of the radiohumeral joint back into anatomical position.

Evidence : Multiple high-quality randomized controlled trials demonstrate that the hyperpronation technique achieves a significantly higher first-attempt reduction rate (85% to 95%) compared to supination-flexion (70% to 75%), while producing less distress in the child.

The Supination-Flexion Technique :

Method : Support the elbow with the thumb over the radial head. Apply slight longitudinal traction, fully supinate the forearm (palm facing upward), and then smoothly and fully flex the elbow bringing the child's hand toward the ipsilateral shoulder.

Endpoint : Palpable click felt over the radial head during terminal flexion.

Clinical Endpoint & Anticipatory Guidance

Children typically cry briefly during reduction. Do not expect instantaneous arm usage.

Clinical Confirmation Protocol : Leave the child quietly in the parent's lap for 10 to 15 minutes . Then, present a desirable stimulus (a colorful toy, sticker, or snack) held above eye level. Successful reduction is confirmed when the child spontaneously and freely reaches overhead with the affected arm using full elbow flexion and supination.

Disposition : No immobilization, sling, cast, or post-reduction radiograph is needed. Educate caregivers that recurrence occurs in 20% to 30% of children prior to age 5; advise all family members to avoid lifting, pulling, or swinging the child by the hands or wrists.

Shoulder (Glenohumeral) Dislocation: Anatomy & Epidemiology

The glenohumeral joint is the most frequently dislocated major diarthrodial joint in the human body, accounting for over 50% of all major joint dislocations. The shallow glenoid fossa articulates with less than one-third of the large spherical humeral head at any given moment, sacrificing intrinsic osseous constraint for multi-axial range of motion.

Classification by Direction :

Anterior Dislocation : > 95% to 97% of all glenohumeral dislocations.

Posterior Dislocation : 2% to 4% of dislocations (frequently missed on initial presentation!).

Inferior Dislocation (Luxatio Erecta) : < 1% (arm locked in hyperabduction overhead).

• Anterior Glenohumeral Dislocation
• Mechanism of Injury & Clinical Presentation

Mechanism : Indirect traumatic force combining abduction, external rotation, and extension (e.g., an athlete's arm tackled while attempting a pass, a volleyball block, or a fall backward onto an outstretched hand).

Physical Inspection : The patient presents in severe distress, supporting the injured arm in slight abduction and external rotation using the contralateral uninjured hand.

The "Squared-Off" Shoulder : The lateral rounded contour of the shoulder formed by the deltoid muscle is completely lost. The prominent lateral edge of the acromion creates a sharp, right-angled "squared-off" shoulder deformity with a hollow subacromial depression.

Palpable Fullness : The dislocated humeral head is readily palpable anteriorly in the subcoracoid or anterior axillary region.

Dugas Sign : The patient is physically unable to place the hand of the injured arm onto the opposite shoulder while keeping the elbow flat against the chest wall.

Mandatory Neurovascular Evaluation: The Axillary Nerve

• Important
• MANDATORY PRE- AND POST-REDUCTION NEUROVASCULAR CHECK

The Axillary Nerve (C5-C6) winds around the surgical neck of the humerus within the quadrangular space, lying immediately adjacent to the inferior glenohumeral capsule. It is injured in 10% to 20% of anterior shoulder dislocations (primarily neuropraxia from traction/compression).

Sensory Testing : Test light touch and pinprick sensation over the lateral aspect of the proximal arm—the "deltoid patch" or "regimental badge area" .

Motor Testing : Palpate for isometric contraction of the anterior and lateral deltoid muscle (instruct the patient to attempt gentle abduction against resistance, pain permitting).

Documentation Requirement : Sensation over the regimental badge area and distal radial pulses MUST be documented in the medical record BEFORE and immediately AFTER closed reduction . AXILLARY NERVE CLINICAL ASSESSMENT

• Deltoid Patch / Regimental Badge Area
• (Lateral Aspect of Proximal Deltoid)
• │
• ▼
• ┌───────────────────────────────┐
• │ SENSATION: Light touch & │
• │ pinprick over deltoid patch │
• ├───────────────────────────────┤
• │ MOTOR: Isometric deltoid │
• │ muscle contraction │
• ├───────────────────────────────┤
• │ PULSE: Radial & ulnar artery │
• │ bounding pulses (<2 sec CRT) │
• └───────────────────────────────┘
• Posterior Glenohumeral Dislocation

Posterior shoulder dislocations represent only 2% to 4% of shoulder dislocations, yet over 50% of posterior dislocations are missed on initial presentation in emergency and primary care clinics, leading to chronic locked dislocations and permanent functional impairment.

The Classic Etiological Triad

Posterior dislocation occurs when the powerful internal rotators (latissimus dorsi, subscapularis, pectoralis major) overpower the relatively weaker external rotators (infraspinatus, teres minor), forcefully driving the humeral head posteriorly out of the glenoid fossa. This is classically triggered by:

• Generalized Tonic-Clonic Epileptic Seizures ;
• High-Voltage Electrical Shocks / Electrocution ;

Lightning Strikes .

(Less commonly, severe direct frontal trauma to the adducted shoulder).

Clinical Presentation & Radiographic Hallmarks

Clinical Presentation : The injured arm is held tightly locked in fixed adduction and internal rotation . The patient has an absolute inability to externally rotate the shoulder past neutral ! Inspection reveals anterior shoulder flattening, a prominent coracoid process, and a palpable posterior fullness beneath the acromion.

The Radiographic Trap on AP View : On standard anteroposterior radiographs, posterior dislocations appear deceptively normal because the humeral head remains centered in the vertical plane. Critical AP clues include:

The "Lightbulb Sign" : Fixed internal rotation projects the spherical humeral head symmetrically without the normal lateral projection of the greater tuberosity, resembling a rounded lightbulb.

The "Trough Line" (Reverse Hill-Sachs) : A vertical dense impaction line on the anteromedial humeral head where it impacts the posterior glenoid rim.

Widened Glenohumeral Joint Space ("Rim Sign") : Distance >6 mm between the anterior glenoid rim and the humeral articular cortex.

MANDATORY DIAGNOSTIC VIEWS : A standard AP radiograph alone is completely insufficient! An Axillary Lateral View or Scapular Y (Outlet) View is mandatory; the axillary view is 100% definitive, clearly demonstrating the humeral head displaced posteriorly relative to the glenoid fossa.

Diagnostic Radiographic Series for Shoulder Dislocations

Prior to performing closed reduction, a dedicated 3-view shoulder radiographic series must be obtained to confirm the direction of dislocation and exclude displaced surgical neck fractures (which carry a high risk of iatrogenic head displacement or avascular necrosis during closed reduction attempts):

• True Anteroposterior (Grashey) View ;
• Scapular Y (Outlet) View ;

Axillary Lateral View (or Velpeau Axillary View if the arm cannot be abducted).

Following reduction, a repeat complete 3-view series is mandatory to verify concentric reduction and evaluate for associated osseous fractures.

Closed Reduction Techniques for Anterior Dislocation

Adequate muscle relaxation and analgesia are essential. Intra-articular Lidocaine Injection (20 mL of 1% plain lidocaine injected into the glenohumeral space 2 cm inferior and lateral to the posterior acromion under sterile technique) provides analgesia equal to intravenous procedural sedation, with lower costs, shorter clinic times, and zero risk of opioid/sedative-induced respiratory depression. CLOSED REDUCTION TECHNIQUES COMPARISON

• Technique Mechanism & Patient Position Clinical Advantages
• ─────────────────────────────────────────────────────────────────────────────
• Milch Supine; gradual overhead Gentle, atraumatic;
• abduction + external rotation; >90% success rate;
• gentle anterior pressure on head minimal patient pain

• Cunningham Seated upright; arm at side; No traction; relies on
• massage trapezius, deltoid, & muscle relaxation;
• biceps while patient relaxes superb in elderly

• Scapular Prone (hanging arm) or seated; Rotates glenoid into
• Manipulation push inferior angle of scapula humeral head; >85% success;
• medially toward spine low force required

• Hennepin Seated or supine; elbow 90°; Slow millimeter rotation;
• (Ext Rotation) slowly externally rotate arm low complication rate;
• to 70°-80°; spontaneous slip gentle & controlled
• ─────────────────────────────────────────────────────────────────────────────

The Milch Technique :

Method : Patient supine. The clinician gently and progressively abducts and externally rotates the arm into the overhead position over 5 to 10 minutes. Once fully abducted overhead, gentle longitudinal axial traction is applied while the clinician uses fingers in the axilla to push the humeral head superiorly and anteriorly over the glenoid rim.

Advantages : Highly successful (>90%), gentle, and well-tolerated.

The Cunningham Technique (Massage / Relaxation) :

Method : The patient sits upright in a chair with the arm adducted at the side and elbow flexed to 90°. The examiner kneels and places the patient's hand on the examiner's shoulder. The clinician systematically massages the trapezius, deltoid, and biceps brachii muscles to abolish spasm while instructing the patient to relax the shoulders downward and backward. Within several minutes of relaxation, the humeral head slips effortlessly back into the glenoid without traction.

Scapular Manipulation :

Method : Patient prone with the injured arm hanging dependent over the edge of the examination table (with 5 to 10 lbs of hanging weights), or seated upright. The clinician stabilizes the superior aspect of the scapula with one hand and uses the other hand to push the inferior angle of the scapula medially toward the vertebral column.

Mechanism : Rotates the glenoid fossa to realign with the dislocated humeral head.

The Hennepin (External Rotation) Technique :

Method : Patient supine or seated with the elbow flexed to 90° against the torso. The clinician gently and slowly externally rotates the forearm millimeter by millimeter over several minutes. When external rotation reaches 70° to 85° , reduction typically occurs spontaneously without any traction.

Associated Lesions & Age-Dependent Recurrence Risk

Traumatic glenohumeral dislocation disrupts stabilizing osseous and soft-tissue constraints, producing characteristic structural lesions:

Bankart Lesion : Detachment or avulsion of the anteroinferior glenoid labrum from the underlying fibrous glenoid rim, present in >85% to 90% of traumatic anterior dislocations . A "Bony Bankart" involves an avulsion fracture of the anterior glenoid rim; bone loss >20% to 25% requires surgical reconstruction (Latarjet coracoid transfer).

Hill-Sachs Lesion : A posterolateral humeral head compression fracture resulting from forceful impaction against the hard anterior glenoid rim during dislocation. Present in up to 80% of anterior dislocations and nearly 100% of recurrent cases.

Rotator Cuff Tears : Highly prevalent in older patients! While rare in patients <30 years (<5%), full-thickness rotator cuff tears occur in 30% to 60% of patients >40 years and >80% of patients >60 years following an acute dislocation. Any patient >40 years who exhibits persistent weakness in abduction or external rotation following reduction must undergo non-contrast MRI to evaluate for acute rotator cuff disruption.

Recurrence Stratification by Patient Age

The single most critical predictor of recurrent shoulder dislocation is patient age at initial injury :

Patient Age Group Recurrence Rate Long-Term Clinical Implications

Age <20 Years 70% to 90% Exceptionally high recurrence; early orthopedic referral for surgical labral repair (Bankart repair) in competitive contact athletes

Age 20 to 40 Years 40% to 60% Moderate recurrence rate; trial of conservative rehabilitation vs. surgery based on athletic demands

Age >40 Years <10% to 15% Low recurrent dislocation risk; high incidence of concurrent rotator cuff tears and axillary nerve injuries

Post-Reduction Management & Rehabilitation Protocol

Immobilization : Standard sling immobilization for 1 to 2 weeks solely for pain control. Prolonged immobilization (>2 weeks) is strongly discouraged because randomized trials show it does NOT decrease recurrence rates and promotes joint capsule stiffness and muscular atrophy.

Rehabilitation : Initiate early protected isometric periscapular and rotator cuff strengthening exercises at 1 to 2 weeks, progressing to active-assisted range of motion. Restrict combined abduction and external rotation for at least 6 weeks.

Loading diagram... Glenohumeral Dislocation Assessment & Management Pathway