Nursemaid's elbow

Background

  • Radial head subluxation due to longitudinal traction on arm
    • Annular ligament of radius displaces into radiocapitellar articulation
  • Age 1y-5y (peak 2y-3y)
    • After this point, the change in shape of the radial head with growth protects against subluxation

Clinical Features

  • Typical history includes sudden longitudinal traction on the arm
    • Swinging child by arms by playing
    • Pulling child back from walking into traffic
    • Catching child who is falling
  • Younger children may sustain the injury by less classic mechanisms
  • Sudden onset of pain
  • Refusal to use the affected arm
  • Arm held in extension
  • Refusal to supinate
  • Limited edema
  • No bruising

Differential Diagnosis

Elbow Diagnoses

Radiograph-Positive

Radiograph-Negative

Pediatric

Evaluation

  • Clinical diagnosis
    • Patients with classic story and findings do not require imaging before reduction
    • Any child with an unclear story or unsuccessful reduction should undergo imaging to rule other pathology
  • Assess neurovascular status prior to (and following) reduction

Management

Reduction

Hyperpronation has greater first attempt success (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
      • Place thumb over radial head to facilitate reduction and provide tactile feedback
    • With other hand hyperpronate patient's wrist
  • Supination Technique
    • Hold patient's elbow at 90 degrees with one hand
      • Place thumb over radial head to facilitate reduction and provide tactile feedback
    • With other hand supinate patient's wrist and fully flex elbow

Post-Reduction

  • If successful, patient will have return of full range of motion within 30min
    • Usually child with begin to spontaneously use the affected arm
    • If child is not using affected arm, may try offering a popsicle or toy and encouraging to reach with affected arm
  • If unsuccessful after multiple attempts, obtain x-ray and consider alternative diagnoses (e.g. Salter-Harris fracture)

Disposition

  • Discharge home after successful reduction
  • No immobilization
  • Caution caregivers to avoid longitudinal traction on arm
  • Advise caregivers that injury is frequently recurrent until radial head maturity

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.