Elbow

Nursemaid's Elbow

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Nursemaid's Elbow, Pulled Elbow, Radial Head Subluxation

  • General
  1. Radial head subluxed beneath orbicular ligament
  • Epidemiology
  1. Most common between age 1-3 years
  2. Rare after 6 years old
  • Mechanism
  1. Results from longitudinal traction on hand
    1. Elbow extended
    2. Forearm pronated
  2. Often occurs when child lifted by wrist or hand
  • Symptoms and Signs
  1. Audible snap may be heard with Radial Head Subluxation
  2. Arm is held motionless at side
    1. Slight flexion
    2. Pronation
    3. Adduction
  3. Radial Head tender
  • Imaging
  1. Elbow XRay Normal
  • Management
  • Reduction
  1. Images
    1. ElbowNursemaidsReduction.jpg
  2. Technique 1
    1. Cup affected elbow with opposite hand
    2. Apply pressure over radial head
      1. Thumb in antecubital fossa
    3. Apply slight longitudinal traction by grasping wrist
    4. Supinate (palm up) and flex (to 90 degrees) Forearm
    5. Palpable click felt with reduction
  3. Technique 2 (higher efficacy than supination with flexion)
    1. Elbow held in flexion
    2. Examiner positions thumb over radial head
    3. Hyperpronate Forearm
    4. Macias (1998) Pediatrics 102(1): e10 [PubMed]
  • Management
  • Post-reduction
  1. Child uses arm within 10-15 minutes
    1. Immobilization optional (Sling for 1-2 days)
  2. 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
      2. Re-evaluate in 24 hours