Nursemaid's elbow

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Background

  • Radial head subluxation due to longitudinal traction on arm
    • Annular ligament of radius displaces into radiocapitellar articulation
  • Age 1y-5y (peak 2y-3y)

Clinical Features

  • Sudden onset of pain and unwillingness to use affected elbow/arm
  • Typical history = sudden pull on extended arm (e.g. swinging the child by arms while playing, pulling child back from walking into intersection, etc)
  • Generally there is no edema, focal tenderness, or bruising

Differential Diagnosis

Elbow Diagnoses

Radiograph-Positive

Radiograph-Negative

Pediatric

Evaluation

  • Generally clinical diagnosis
  • Imaging not required before attempting reduction

Management

Reduction

Hyperpronation has greater first try success rate (94% vs 69%), but both have similar overall reduction rate;[1] consider doing both techniques at once in quick succession

  • Hyperpronation Technique
    • Hold patient's elbow at 90 degrees with one hand
    • With other hand hyperpronate patient's wrist
  • Supination Technique
    • Hold patient's elbow at 90 degrees with one hand
    • With other hand supinate patient's wrist and flex elbow

Post-Reduction

  • If successful patient will have return of full range of motion within 30min
  • If unsuccessful after multiple attempts, obtain x-ray and consider alternative diagnoses (e.g. Salter-Harris fracture)

Disposition

  • Discharge if successful reduction and return of use of arm

See Also

External Links

Video Demonstration Reduction

References

  1. Pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial. Eur J Emerg Med. 2009 Jun;16(3):135-8. doi: 10.1097/MEJ.0b013e32831d796a.