How can an adult get a radial head subluxation without heavy lifting?

Radial Head Subluxation in Adults Without Heavy Lifting

Adults can develop radial head subluxation through sudden pulling or twisting forces on the extended arm, repetitive rotational movements, direct trauma, or spontaneous subluxation in the setting of ligamentous laxity or prior annular ligament injury.

Mechanisms of Injury in Adults

Acute Traumatic Causes

• Sudden traction or pulling forces applied to an extended and pronated forearm, similar to the classic "nursemaid's elbow" mechanism but requiring greater force in adults due to stronger ligamentous structures 1
• Rotational injuries during activities like volleyball or other sports involving rapid forearm rotation, which can rupture or stretch the annular ligament 2
• Direct trauma to the elbow without heavy lifting, such as falls onto an outstretched hand or direct blows to the lateral elbow 3
• Forceful supination or pronation movements during daily activities, particularly when the elbow is extended 4

Recurrent or Chronic Subluxation

• Prior annular ligament injury that healed with laxity, predisposing to recurrent subluxation with minimal provocation 2, 5
• Repetitive rotational activities that gradually stretch the annular ligament over time, even without a single traumatic event 2
• Congenital or acquired ligamentous laxity that allows the radial head to subluxate with normal daily activities 5

Clinical Presentation

Acute Subluxation

• Immediate pain at the lateral elbow following a twisting or pulling motion 1
• Reluctance to use the affected arm, particularly avoiding supination and pronation movements 4
• Palpable or audible click during examination or with forearm rotation 2, 4

Recurrent Subluxation

• Intermittent clicking sensation associated with pain during forearm rotation, particularly with biceps contraction 2
• Episodes triggered by seemingly minor activities such as reaching, turning doorknobs, or lifting light objects 2
• Progressive symptoms over weeks to months if the underlying ligamentous injury is not addressed 5

Diagnostic Approach

Clinical Examination

• Assess for point tenderness over the radial head and lateral elbow 3
• Test forearm rotation in both supination and pronation to reproduce symptoms or clicking 2
• Palpate for radial head subluxation during active biceps contraction or passive forearm rotation 2
• Evaluate for associated injuries including fractures of the radial head, coronoid process, or olecranon, as these commonly occur together 3

Imaging

• Standard radiographs (AP and lateral elbow views) should be obtained first to rule out fractures, though they may appear normal in isolated ligamentous injury 3
• CT without contrast is indicated when radiographs are equivocal or to better characterize fracture morphology if present 3
• Dynamic fluoroscopy or image intensifier examination can demonstrate subluxation during forearm rotation or biceps contraction in cases of recurrent instability 2

Management Considerations

Acute Subluxation

• Reduction maneuvers using supination technique are highly effective, with 100% success rate when a palpable click is felt during reduction 4
• Remanipulation 12-106 hours later is successful in all patients who failed initial reduction 4
• Supination maneuver is particularly effective for patients presenting 2+ hours after injury 4

Recurrent Subluxation

• Annular ligament reconstruction using tendon graft (palmaris longus or fascia lata) is indicated for recurrent instability that fails conservative management 2, 5
• Surgical reconstruction provides stable results with no recurrence at 4+ years follow-up when properly performed 5

Important Clinical Pitfalls

• Missing associated injuries: Radial head subluxation in adults often occurs with other fractures or ligamentous injuries that require identification 3, 6
• Assuming it only occurs in children: While more common in pediatric populations, adults can develop this injury through similar mechanisms or recurrent instability 2, 5
• Inadequate reduction confirmation: A palpable or audible click during reduction strongly predicts successful treatment, with 98% (53/54) achieving arm reuse within 30 minutes 4
• Overlooking chronic ligamentous laxity: Patients with recurrent symptoms may have underlying annular ligament insufficiency requiring surgical reconstruction rather than repeated closed reductions 2, 5