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Nursemaids Elbow

From WikiSM

Other Names

  • Subluxation of the annular ligament
  • Subluxation of the radial head
  • Pulled Elbow
  • Radial Head Subluxation

Background

History

  • Needs to be updated

Epidemiology

  • Most often ages 1 to 4 with average age 28 months (need citation)

Introduction

Annular Ligament of the radius
Illustration of Nursemaid's Elbow[1]

General

  • Sudden traction at the hand or wrist leading to pronated forearm and extended elbow
  • Can also occur after a minor fall[2]
  • Reported in infants who roll over on their arm, trapping under body while sleeping[3]

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

Anatomy of the Annular Ligament

  • Strong, circular ligamentous band that anchors the Radius to the radial notch of the Ulna

Risk Factors

  • Age (1-4)

Differential Diagnosis

Differential Diagnosis Elbow Pain

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

  • Primary a clinical diagnosis, helpful to exclude other etiologies
    • Imaging is not required if the story fits the classic presentation

Radiographs

  • Standard Radiographs Elbow
    • Typically normal when obtained
    • May demonstrate abnormal 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
  • Nursemaids Elbow Reduction
    • Hyperpronation technique favored over Supination & Flexion[4]

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

  • Recurrence
    • Rarely, recurrent subluxations
    • However one study estimates rate ranges between 27% and 39% (need citation)

See Also

Internal

External

References

  1. ↑ Image courtesy of www.childrenshospital.org/, "Nursemaid's Elbow"
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ Aksel G, Küka B, İslam MM, Demirkapı F, Öztürk İ, İşlek OM, Ademoğlu E, Eroğlu SE, Satıcı MO, Özdemir S. Comparison of supination/flexion maneuver to hyperpronation maneuver in the reduction of radial head subluxations: A randomized clinical trial. Am J Emerg Med. 2024 Nov 18;88:29-33. doi: 10.1016/j.ajem.2024.11.026. Epub ahead of print. PMID: 39579408.
Created by:
John Kiel on 18 June 2019 01:13:45
Authors:
Last edited:
11 December 2024 16:02:58
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