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
Radiograph-Positive
- Distal humerus fracture
- Radial head fracture
- Capitellum fracture
- Olecranon fracture
- Elbow dislocation
Radiograph-Negative
- Lateral epicondylitis
- Medial epicondylitis
- Olecranon bursitis (nonseptic)
- Septic bursitis
- Biceps tendon rupture/dislocation
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
- Hold patient's elbow at 90 degrees with one hand
- 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
- Hold patient's elbow at 90 degrees with one hand
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
References
- 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.
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