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Nursemaids Elbow

From WikiSM

Other Names

  • Subluxation of the annular ligament
  • Pulled Elbow
  • Radial Head Subluxation
  • Nursemaid's Elbow
  • Nursemaids Elbow
  • Subluxation of the Radial Head
  • Radial Head Displacement
  • Elbow Pulled Out

Background

History

  • French surgeon D Fournier published the first case of radial head subluxation in 1671[1]

Epidemiology

  • Approximately 20,000 ED visits annually in the United states[2]
  • Incidence is 2.4 to 2.7 per 1000 children[3]
  • Median age at presentation is 2.0–2.5 years (mean ~28.6 months)[4]

Introduction

Anatomy and pathophysiology of Nursemaid's elbow[5]
Annular Ligament of the radius
Illustration of Nursemaid's Elbow[6]
Schematic diagrams illustrating the pathology of nursemaid's elbow in the coronal section at the level of the most projecting part of the lateral epicondyle. A, Normal elbow: the posterior fringe is located in its normal position between the capitella and radial head. B, Nursemaid's elbow: The posterior synovial fringe entrapped between the radial head epiphysis and annular ligament. "a" indicates extensor digitorum muscle, "b" indicates extensor carpi radialis brevis, and "S" indicates supinator. Bold arrow indicates posterior synovial fringe and thin arrow indicates annular ligament.[7]

General

  • Defined as subluxation of the radial head from the annular ligament of the elbow
  • It is most common upper extremity musculoskeletal injury in children under 5 years of age[8]
  • Characterized by traction at the hand or wrist leading to pronated forearm and extended elbow
  • The diagnosis is clinical based on history and physical exam, imaging is typically unnecessary
  • Treatment is reduction at the bedside with resolution of symptoms in most patients

Mechanism of Injury

  • Classic mechanism: axial traction (sudden pull) on the extended, pronated arm usually by an adult or taller person
    • Accounts for ~63–66% of cases[9]
  • Common traction scenarios[9]
    • Lifting the child by the arms (28.3%)
    • "Wrestling" with the child (12.3%)
    • Swinging the child by the arms (9.2%)
    • Pulling the child away from a dangerous situation or up a curb/step
    • Child pulling away from an adult impulsively
  • Approximately one-third of patients present with a nonclassical history
    • Can also occur after a minor fall[10]
    • Reported in infants who roll over on their arm, trapping under body while sleeping[9]
  • Male caregivers are more commonly involved in swinging (OR 3.2) and wrestling (OR 6.4)[9]

Etiology

  • Sudden longitudinal traction pulls the radial head distally through the annular ligament
  • 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
  • Stabilizes the proximal radioulnar joint while allowing rotation pronation/supination
  • In young children, the annular ligament is thin and weakly attached to the radial neck
    • Thus it is susceptible to displacement

Associated Conditions

  • Joint Hypermobility
    • 73% of children with pulled elbow had joint hypermobility[11]
  • Congenital radial head dislocation/subluxation

Risk Factors

  • Age (1-4)[11]
    • immature annular ligament and cartilaginous, less bulbous radial head
  • Female Sex[12]
    • Girls comprise 56–60% of cases
    • Recurrence is more common in males
  • Left arm predominance
    • Represents 52-60% of cases
    • Likely related to the dominant hand of the caregiver pulling the child's non-dominant arm
  • Higher body weight
  • Joint Hypermobility
  • Caregiver related
    • Activities involving lifting, swinging, or wrestling with the child
    • Male caregivers are disproportionately involved in higher-risk play mechanisms
  • Prior subluxation

Differential Diagnosis

Differential Diagnosis Elbow Pain

Clinical Features

Clinical picture showing the child’s left upper limb in pronated position[13]

History

  • Mechanism will generally involve a longitudinal traction force on the affected extremity
    • Arm is in extension, pronated
    • The parent may report a click during the episode
  • Pain
    • Child will suddenly cry out
    • The child will refuse to move arm, holds elbow in flexion and pronation
    • Can be referred to wrist or elbow
  • About half of children have had a prior elbow
  • Most obtain thoughtful history to exclude non accidental trauma

Physical: Physical Exam Elbow

  • Arm is held in flexion, pronation[14]
    • Child refuses to move it
    • Sometimes "Pseudoparalysis"
  • Swelling and bruising are typically absent
  • Pain, tenderness to lateral elbow
    • Typically less focal, absent bony tenderness
  • Flexion and extension intact
    • Pain when supinating forearm
  • Neurovascular status should be normal

Special Tests

  • There are no validated special tests for Nursmaids Elbow

Evaluation

A, Sonographic image of the left side of a nursemaid's elbow in a boy aged 4 years and 5 months. The posterior fringe (arrow) was entrapped between the radial head epiphysis and annular ligament. It obscured the radial head like a solar eclipse. B, After reduction, the "partial eclipse sign" disappeared, and the normal relationship between the radial head and annular ligament returned. The radial head epiphysis is rounded again (arrow).[7]

General

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

Radiographs

  • Standard Radiographs Elbow
    • Not routinely required
    • Typically normal when obtained
  • In a large ED Study[15]
    • Radiographs were obtained in 28.5% of cases, with wide hospital-level variation (19.8–41.7%)
    • Missed fractures were rare at only 0.3%
  • Indications for imaging
    • Atypical or unclear mechanism of injury (e.g., fall rather than pull)
    • Nonambulatory infant
    • Presence of swelling, ecchymosis, or point tenderness
    • Failed reduction attempts
    • Concern for non-accidental trauma
    • Age over 5
    • Difficult reduction
  • Potential findings

Ultrasound

  • Benefits[17]
    • Radiation free
    • Performed at bedside
    • Redueces ED length of stay compared to radiograph (61 min vs 103 min)
  • J-sign
    • Probe: anterior long-axis view of the radiohumeral joint (12 MHz transducer)
    • Entrapped annular ligament and supinator muscle produce a characteristic hypoechoic J-shaped image
    • Present in 100% of cases (70 patients) before reduction and disappeared after successful manipulation[18]
  • Partial eclipse sign
    • Probe: axial view of the radial head using a high-frequency hockey stick transducer (6–24 MHz)
    • The escaped posterior synovial fringe produces a partial eclipse appearance over the radial head
    • Present in all 13 patients before reduction and absent after successful reduction[18]
  • Entrapped supinator sign[19]
    • Supinator muscle, originating from the annular ligament, becomes trapped within the radiohumeral joint
    • After reduction, the supinator appears disentangled and swollen, and the annular ligament is restored

Classification

  • There is no formal classification or grading system

Management

Illustration of Supination & Flexion and the Hyperpronation techniques[20]
Hyperpronation Technique
Supination Flexion Technique

Nonoperative

  • Indications
    • First line in virtually all cases
    • The vast majority of cases are managed nonoperatively

Hyperpronation Technique

  • Preferred and first line maneuver
  • Favored over Supination & Flexion[21]
    • Significantly lower first-attempt failure rates (9.4%) compared to supination-flexion (25%)[22]
  • Description[23]
    • Stabilize the child's elbow at 90° of flexion with one hand while
    • Grasp the child's hand in a handshake grip with the other
    • Apply firm hyperpronation (rotating the forearm inward, palm facing downward)
    • While maintaining gentle pressure over the radial head with the thumb
    • A palpable or audible click over the radial head typically confirms successful reduction

Supination Flexion Technique

  • Description
    • Stabilize the elbow with one hand while grasping the child's wrist with the other
    • Apply firm supination (rotating the forearm outward, palm facing upward)
    • Then fully flex the elbow so the wrist is directed toward the ipsilateral shoulder
    • While maintaining thumb pressure over the radial head
  • First-attempt success rate is lower than hyperpronation at 68–77%[24]

Operative

  • Indication
    • Chronic, symptomatic subluxations that will not maintain stable reduction
  • Technique
    • Open Reduction

Rehab and Return to Play

Rehabilitation

  • Formal rehabilitation is not routinely indicated
  • The condition is considered a benign, self-limited injury

Return to Play

  • Child can immediately return to normal activity

Complications & Prognosis

Prognosis

  • Overall, prognosis is excellent
  • No documented long-term sequelae after successful reduction
  • Condition is considered entirely benign and self-limited

Complications

  • Recurrence
    • Rarely, recurrent subluxations
    • However one study estimates rate ranges between 27% and 39%[25]
    • Male sex and younger age increased risk
  • Missed fracture
    • One study found missed fracture rate to be 0.3%[15]

See Also

Internal

External

References

  1. ↑ Fournier D. 1671. First published description of radial head subluxation in children
  2. ↑ Welch, Rachel, Thiphalak Chounthirath, and Gary A. Smith. "Radial head subluxation among young children in the United States associated with consumer products and recreational activities." Clinical Pediatrics 56.8 (2017): 707-715.
  3. ↑ Krul, Marjolein, et al. "Manipulative interventions for reducing pulled elbow in young children." Cochrane Database of Systematic Reviews 1 (2012).
  4. ↑ Pirruccio, Kevin, Daniel Weltsch, and Keith D. Baldwin. "Reconsidering the “Classic” clinical history associated with subluxations of the radial head." Western Journal of Emergency Medicine 20.2 (2019): 262.
  5. ↑ Singh, Anushi. "Nursemaid elbow: Elbow subluxation."
  6. ↑ Image courtesy of www.childrenshospital.org/, "Nursemaid's Elbow"
  7. ↑ 7.0 7.1 Tsai, Chia-Che, and Yi-Pin Chiang. "The usefulness of dynamic ultrasonography in nursemaid’s elbow: a prospective case series of 13 patients reconsideration of the pathophysiology of nursemaid’s elbow." Journal of Pediatric Orthopaedics 43.6 (2023): e440-e445.
  8. ↑ David, MIRIAM L. "Radial head subluxation." American Family Physician 35.4 (1987): 143-146.
  9. ↑ 9.0 9.1 9.2 9.3 Rudloe, Tiffany F., et al. "No longer a “nursemaid’s” elbow: mechanisms, caregivers, and prevention." Pediatric emergency care 28.8 (2012): 771-774.
  10. ↑ 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.
  11. ↑ 11.0 11.1 Hagroo, G. A., et al. "Pulled elbow—not the effect of hypermobility of joints." Injury 26.10 (1995): 687-690.
  12. ↑ Rudloe, Tiffany F., et al. "No longer a “nursemaid’s” elbow: mechanisms, caregivers, and prevention." Pediatric emergency care 28.8 (2012): 771-774.
  13. ↑ Ibrahim, Mohd Ikraam, et al. "Pulled Elbow Syndrome in Infants below 2 Years of Age: A Rare Entity." Gazi Medical Journal 28.2 (2017).
  14. ↑ Yamanaka, Syunsuke, and Ran D. Goldman. "Pulled elbow in children." Canadian Family Physician 64.6 (2018): 439-441.
  15. ↑ 15.0 15.1 Genadry, Katia C., et al. "Management and outcomes of children with nursemaid’s elbow." Annals of Emergency Medicine 77.2 (2021): 154-162.
  16. ↑ Lee, Soon Hyuck, et al. "The usefulness of ultrasound and the posterior fat pad sign in pulled elbow." Injury 50.6 (2019): 1227-1231.
  17. ↑ Arnowitz, Elisheva, and Eric Scheier. "POCUS for Pulled Elbow Due to Trauma: A Retrospective Review and Case Series." Pediatric Emergency Care (2024): 10-1097.
  18. ↑ 18.0 18.1 Dohi, Daisuke. "Confirmed specific ultrasonographic findings of pulled elbow." Journal of Pediatric Orthopaedics 33.8 (2013): 829-831.
  19. ↑ Lee, Soon Hyuck, et al. "The usefulness of ultrasound and the posterior fat pad sign in pulled elbow." Injury 50.6 (2019): 1227-1231.
  20. ↑ Image courtesy of SAEM.org, "Nursemaid's Elbow"
  21. ↑ 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.
  22. ↑ Bexkens, Rens, et al. "Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: a systematic review and meta-analysis." The American journal of emergency medicine 35.1 (2017): 159-163.
  23. ↑ Yamanaka, Syunsuke, and Ran D. Goldman. "Pulled elbow in children." Canadian Family Physician 64.6 (2018): 439-441.
  24. ↑ Macias, Charles G., Joan Bothner, and Robert Wiebe. "A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations." Pediatrics 102.1 (1998): e10-e10.
  25. ↑ Schunk, Jeff F. "Radial head subluxation: epidemiology and treatment of 87 episodes." Annals of emergency medicine 19.9 (1990): 1019-1023.
Created by:
John Kiel on 18 June 2019 01:13:45
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Last edited:
2 July 2026 20:00:24
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