FAST TRACK: Nursemaid’s Elbow
CASE
A 3-year-old female is brought into the Emergency Department for left arm pain. She was at the park earlier today when she suddenly ran towards the street - her father pulled her back by the arm and felt a slight “click”. She immediately started crying and has refused to move or bend the arm since.
DIAGNOSIS
Radial head subluxation (commonly referred to as a Nursemaid’s elbow)
DISCUSSION
Nursemaid’s elbow is a common injury in young children in which the radial head slips under the annular ligament resulting in pain and inability to supinate the forearm. The annular ligament encircles the radial head and holds it against the ulna. Axial traction on a pronated forearm and extended elbow causes the annular ligament to slip over the head of the radius and become trapped in the radio-humeral joint between the radial head and capitellum [1]. Bruising, swelling, and point tenderness are not typically present with this injury.
Figure 1 Depiction of mechanism of injury for radial head subluxation (nursemaid's elbow) [5]
It is most common in children from 1 to 4 years of age. The typical history includes injury resulting from sudden longitudinal traction on the arm (ex: swinging a child by the arms while playing, pulling a child back from walking into traffic, or catching a child who is falling). Clinically, children present with sudden onset of pain, refusal to use the affected arm, holding the arm in extension, refusal to supinate, and limited swelling or bruising [2].
Radiographs are not required if patients present with a classic history and clinical findings. When obtained, radiographs are normal [3]. Any child with an unclear story or unsuccessful reduction should undergo imaging to rule out other pathology.
Management of a nursemaid’s elbow includes closed reduction with either hyperpronation or supination techniques. Neurovascular status should be assessed prior to and following reduction. Hyperpronation has a greater first attempt success (94% vs. 69%), but both have similar overall reduction rate [4].
Hyperpronation Technique:
For the hyperpronation technique, hold the patient’s elbow at 90 degrees with one hand, and place the thumb over the radial head to facilitate reduction. With the other hand, hyperpronate the patient’s wrist. A click is usually felt over the radial head which indicates the maneuver was successful [1].
Figure 2 Hyperpronation technique for reduction of nursemaid’s elbow [3]
Supination Technique:
For the supination technique, hold the patient’s elbow at 90 degrees with one hand, and place the thumb over the radial head to facilitate reduction. With the other hand, supinate the patient’s wrist and fully flex the elbow. A click may be felt or heard if the maneuver is successful [1].
Figure 3 Supination technique for reduction of nursemaid's elbow [3]
If reduction is successful, the patient will have return of full range of motion within 30 minutes. Usually, the child will begin spontaneously ranging the affected arm. If reduction is unsuccessful after multiple attempts, consider radiograph imaging and consider alternative diagnoses.
The patient may be discharged home after successful reduction and does not require immobilization. Parents or caregivers should be cautioned to avoid longitudinal traction on the arms and should also be advised that recurrent injury is common until the radial head matures [2].
TAKE-AWAYS
Nursemaid’s elbow (radial head subluxation) occurs primarily in young children ages 1-4, resulting from a longitudinal force on the arm.
Children typically present with pain, the affected arm held in extension, and inability to supinate the arm. Bruising and swelling is atypical, and patients usually have minimal point tenderness.
Nursemaid’s elbow is a clinical diagnosis, and radiographs are usually not required
Reduction may be performed using the hyperpronation or the supination technique. If reduction is successful, patients will begin ranging the arm within approximately 30 minutes.
Patients who undergo successful reduction do not require immobilization. Caregivers should be cautioned regarding mechanism of injury and possibility of recurrence in young children.
Author: Lindsey Brown, MD is a current second year resident at Brown Emergency Medicine
Faculty Reviewer: Michelle Myles, MD is an attending physician at Rhode Island Hospital and Miriam Hospital.
REFERENCES:
1. Nardi, Naomi M. “Nursemaid Elbow.” StatPearls [Internet]., U.S. National Library of Medicine, 14 Aug. 2023, www.ncbi.nlm.nih.gov/books/NBK430777/. Accessed 20 Feb. 2024.
2. Donaldson, Ross et al. “Nursemaid’s Elbow.” WikEM, 15 July 2021, wikem.org/wiki/Nursemaid%27s_elbow. Accessed 20 Feb. 2024.
3. Shaath, KareemS, and Eric Shirley. “Nursemaid’s Elbow.” Orthobullets, 21 Aug. 2022, www.orthobullets.com/pediatrics/4012/nursemaids-elbow. Accessed 20 Feb. 2024.
4. Bek D;Yildiz C;Köse O;Sehirlioğlu A;Başbozkurt M; “Pronation versus Supination Maneuvers for the Reduction of ‘Pulled Elbow’: A Randomized Clinical Trial.” European Journal of Emergency Medicine : Official Journal of the European Society for Emergency Medicine, U.S. National Library of Medicine, June 2009, pubmed.ncbi.nlm.nih.gov/19262394/. Accessed 20 Feb. 2024.
5. professional, Cleveland Clinic medical. “Nursemaid’s Elbow.” Cleveland Clinic, 26 Oct. 2023, my.clevelandclinic.org/health/diseases/22109-nursemaid-elbow. Accessed 20 Feb. 2024.