Nursemaid's elbow

Background

Anterior capsule of elbow-joint. Nursemaid's elbow involves the head of radius slipping out from the anular ligament of radius.

• 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

• Distal humerus fracture
• Radial head fracture
  • Essex-Lopresti fracture
• Capitellum fracture
• Olecranon fracture
• Elbow dislocation

Radiograph-Negative

• Biceps tendon rupture/dislocation
• Lateral epicondylitis
• Medial epicondylitis
• Olecranon bursitis (nonseptic)
• Pronator teres syndrome
• Septic bursitis

Pediatric

• Nursemaid's elbow
• Supracondylar fracture
• Lateral epicondyle fracture
• Medial epicondyle fracture
• Olecranon fracture
• Radial head fracture
• Salter-Harris fractures

Evaluation

• Clinical diagnosis
  • Patients with classic story (toddler 1-3 years old, low energy mechanism) and findings (no bruising/swelling, no point tenderness, arm held adducted/pronated) 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; 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

• Elbow diagnoses

External Links

• Merk Manual: How To Reduce a Radial Head Subluxation (Nursemaid's Elbow)

Videos

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