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Nursemaids Elbow

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Other Names

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

Background

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
    • 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

Pathoanatomy

Risk Factors

  • Age (1-4)

Differential Diagnosis

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

  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. ↑ 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
Authors:
Last edited:
30 January 2022 15:02:54

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