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Nursemaids Elbow
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Contents
Other Names
- Subluxation of the annular ligament
- Subluxation of the radial head
- Pulled Elbow
Background
- This page to subluxation of the Radial Head from the Annular Ligament, commonly termed 'Nursmaid's Elbow'
History
Epidemiology
- General
- Common
- Most often ages 1 to 4 with average age 28 months (need citation)
Pathophysiology

Illustration of Nursemaid's Elbow[1]
- General
Etiology
- The annular ligament becomes interposed into Radiocapitallar Joint, between the radial head and Capitellum
- In older children (i.e. 5+), thickened, stronger distal attachment of annular ligament prevents subluxation
Pathoanatomy
Risk Factors
- Age (1-4)
Differential Diagnosis
- Fractures
- Adult
- Pediatric
- Dislocations & Instability
- Tendinopathies
- Bursopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Other
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
Clinical Features
- History
- Mechanism will generally involve a traction force on the affected extremity
- The parent may report a click during the episode
- The child will refuse to move arm, holds elbow in flexion and pronation
- Physical: Physical Exam Elbow
- Pain, tenderness to lateral elbow
- Flexion and extension intact
- Pain when supinating forearm
- Special Tests
Evaluation
Radiographs
- Primary a clinical diagnosis, helpful to exclude other etiologies
- Imaging is not required if the story fits the classic presentation
- Standard Radiographs Elbow
- Typically normal when obtained
- May demonstrate radiocapitellar line slightly lateral to center of capitellum
- Consider imaging if significant MOI, ecchymosis, swelling, age > 5, difficult reduction
Ultrasound
- May be used to help confirm the diagnosis (need citation)
Classification
- N/A
Management
Nonoperative
- Indications
- First line in virtually all cases
- The majority of cases are managed nonoperatively
- Hyperpronation Technique
- Recommended first line technique due to higher first attempt success rate[4]
- Examiner supports elbow flexed to 90°, applies moderate pressure with finger at the radial head
- Hyperpronate the patients forearm with other hand
- Supination & Flexion Technique
- Physician places thumb over radial head
- Hold patients arm in supination
- Apply maximum flexion
- Physician will likely heal a palpable click with reduction of the radial head
- Post reduction
- Child typically has full range of motion within 10-30 minutes
- Will begin spontaneously moving affected arm
- Can challenge with item of interest (i.e. bottle, popsicle, etc)
- If unsuccessful reduction, recommend obtain radiographs and consider alternative diagnosis
Operative
- Indication
- Chronic, symptomatic subluxations that will not maintain stable reduction
- Technique
- Open Reduction
Rehab and Return to Play
Rehabilitation
- Does not apply due to age
Return to Play
- Does not apply due to age
Complications & Prognosis
Prognosis
- Prognosis is excellent
Complications
- Rarely, recurrent subluxations
See Also
References
- ↑ Image courtesy of www.childrenshospital.org/, "Nursemaid's Elbow"
- ↑ Macias CG, Wiebe R, Bothner J. History and radiographic findings associated with clinically suspected radial head subluxations. Pediatr Emerg Care 2000; 16(1):22-25.
- ↑ Rudloe TF, Schutzman S, Lee LK, Kimia AA. No longer a "nursemaid's" elbow: mechanisms, caregivers, and prevention. Pediatr Emerg Care 2012; 28(8):771-774.
- ↑ 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.
Created by:
John Kiel on 18 June 2019 01:13:45
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Last edited:
30 January 2022 15:02:54
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