Nursemaid's Elbow

Aka: Nursemaid's Elbow, Pulled Elbow, Radial Head Subluxation

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II. Definitions

  1. Nursemaid's Elbow (Radial Head Subluxation)
    1. Radial head subluxed beneath orbicular ligament

III. Epidemiology

  1. Most common between age 1-3 years
  2. Rare after 6 years old

IV. Mechanism

  1. Often occurs when child lifted by wrist or hand
  2. Results from longitudinal traction on hand
    1. Elbow extended
    2. Forearm pronated

V. Symptoms

  1. Audible snap may be heard with Radial Head Subluxation
  2. Typically follows mechanism described above

VI. Signs

  1. Normal neurovascular exam in classic Nursemaid's Elbow
  2. Radial Head tender (and may be palpable)
  3. Arm is held motionless at side
    1. Slight flexion
    2. Pronation
    3. Adduction

VII. Imaging

  1. Elbow XRay Normal
    1. Not required in a classic Nursemaid's Elbow presentation
    2. Indications for XRay
      1. Trauma or fall
      2. Suspected Nonaccidental Trauma
      3. Elbow localized Bruising or swelling
      4. Failed reduction (see below)

VIII. Management: Reduction

  1. Contraindications to Reduction
    1. Nursemaid's Elbow with associated Fracture (or suspected Fracture from Trauma or fall)
  2. Positioning (same for both techniques)
    1. Caregiver holds child on their lap
    2. Child's affected elbow at 90 degrees
    3. Examiner stabilizes affected elbow with their directly opposite hand
      1. Examiner cups the olecranon in their palm
      2. Examiners thumb applies pressure at the radial head (with thumb in antecubital fossa)
    4. Examiner grasps the patient's wrist with their other hand
      1. Apply slight longitudinal traction with the hand grasping the patient's wrist
  3. Technique 1: Hyperpronation
    1. Higher efficacy (90%) than supination with flexion
    2. Quickly Hyperpronate Forearm
      1. Rotate Forearm palm down to facing laterally (with thumb medial)
    3. May consider flexing elbow as done in the supination technique
    4. Perform supination and flexion if hyperpronation fails
  4. Technique 2: Supination and Flexion
    1. Images
      1. ElbowNursemaidsReduction.jpg
    2. Quickly supinate the Forearm (rotating palm up, thumb lateral) AND fully flex elbow (wrist approaches Shoulder)
  5. Signs of successful reduction
    1. Palpable click felt with reduction
    2. Child begins using the elbow in the subsequent 15-30 minutes

IX. Management: Post-Reduction

  1. Perform neurovascular exam
  2. Child uses arm within 10-15 minutes
    1. Immobilization optional (Sling for 1-2 days)
  3. Child fails to use arm after 15 minutes
    1. Obtain Elbow XRay to rule out concomitant Fracture
    2. Elbow XRay normal but child still not using arm
      1. Posterior splint and sling with elbow at 90 degrees
      2. Re-evaluate in 24 hours

X. References

  1. Warrington (2023) Crit Dec Emerg Med 37(2): 16-7
  2. Claudius, Sacchetti and Seiden (January, 2024) EM:Rap
  3. Macias (1998) Pediatrics 102(1): e10 [PubMed]

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