Nursemaid's Elbow
Objectives
Upon finishing this module, the student will be able to:
- Recognize the typical presentation of Nursemaid's Elbow (aka Radial Head Subluxation).
- Understand the pathogenesis of Nursemaid's Elbow.
- Understand the approach to reduction techniques used.
Contributors
Update Authors: Keith Henry, MD; and Brad Hernandez, MD.
Original Authors: Kevin Kilgore, MD; and Keith Henry, MD.
Update Editor: Steven Lindsey, MD.
Original Editor: S. Margaret Paik, MD.
Last Updated: July 2024
Introduction
Nursemaid's Elbow, more accurately referred to as Radial Head Subluxation, is an injury unique to the pediatric patient. It is the most common elbow-specific injury in the pediatric population. It typically occurs in children six months-three years, and although it has been reported up through pre-teen years, it is rare past four years of age. Radial Head Subluxation occurs when the annular ligament slips away from the radial head, becoming entrapped within the radiohumeral joint. The typical mechanism of injury includes axial traction on a pronated forearm as occurs during play or during common activities of daily living.
A 28-month-old female presents to the emergency department (ED) in the care of her mother. The patient’s mother reports that several hours earlier she and her daughter were holding hands on an afternoon walk. As her child stumbled toward the curb of a sidewalk, the mother quickly pulled the patient up by the hand and wrist to avoid a fall off the sidewalk and into the street. The mother admits that her daughter was momentarily lifted into the air before being placed back down onto her feet. Since the event, the patient has been unwilling to move her left arm for any reason. She resists any attempt of the mother to manipulate or move her arm. The mother is concerned that she may have injured her daughter’s wrist.
While a patient presenting with an isolated Nursemaid’s Elbow is unlikely to be significantly injured or ill, a few components of the primary survey are still of particular importance. First, a complete set of vital signs should be obtained, paying close attention to the presence of a fever, which may indicate an infectious cause for the patient’s symptoms. Additionally, checking for neurovascular compromise to the affected limb is best practice, including pre- and post-reduction motor exams, assessment of capillary refill, and ensuring the presence of a radial pulse. Finally, as with all pediatric orthopedic presentations, potential non-accidental trauma should be considered, particularly if injuries beyond the Radial Head Subluxation are noted.
While all children with Radial Head Subluxation demonstrate limited to no movement of the affected arm, the actual position of the arm may be variable. Full extension at the elbow, a slightly flexed elbow, or an elbow flexed to 90 degrees may be observed. The extremity is held close to the body with the forearm most commonly pronated.
A complete examination of the upper extremity is indicated starting proximally from the clavicle and proceeding distally to the wrist and digits. Tenderness may be produced with any manipulation and palpation over the radial head. Soft tissue swelling in any area of the extremity exam is uncommon with Radial Head Subluxation and should increase a suspicion of fracture. Any attempt to supinate the forearm will produce pain, fussiness, and anxiety as a result of the entrapped annular ligament.
A child presenting with clinical features typical of Radial Head Subluxation should undergo prompt reduction. The rapid and successful nature of proven reduction techniques obviates the need and risk of procedural sedation. Reduction does cause brief discomfort to the patient and it is imperative to prepare the parent or caregiver prior to any attempted manipulation of the extremity.
Two reduction techniques described and commonly utilized in clinical practice include hyperpronation and supination/flexion. While there is an abundance of literature evaluating the two methods, no one technique has been proven superior over the other, indicating that both constitute a reasonable approach for an initial reduction attempt.
Hyperpronation
Hyperpronation has been described with or without a flexion component. With the child ideally seated in the parents lap and facing the examiner, the radial head is located and pressure is applied with the thumb or index finger. With pressure applied to the radial head in a medial direction, the examiner's opposite hand grasps the distal forearm and applies hyperpronation. A palpable and/or audible click may be appreciated at the time of successful reduction. A variation to hyperpronation includes the additional application of flexion at the time of maximal hyperpronation. At the end of the maneuver, the elbow is extended and released.
Supination/Flexion
Similar to hyperpronation, the supination/flexion technique includes placing the child in a caregiver's lap facing the examiner. The radial head is located and pressure is applied with the thumb or index finger. With the examiner's opposite hand, axial traction with supination and flexion of the elbow past 90 degrees is applied in one smooth motion. A palpable and/or audible click may be appreciated at the time of successful reduction.
Figure: hyperpronation vs supination/flexion practitioner hand placement. Used with permission from Nationwide Children's Hospital.
An open-source video demonstrating reduction techniques can be viewed here.
Post Reduction
Response to a successful reduction is variable. A patient may resume usual activity of the affected extremity with unlimited range of motion immediately following reduction. More commonly, a patient will remain apprehensive and unwilling to demonstrate spontaneous movement, as the manipulation will have caused brief pain and heightened anxiety. As such, reassessment in a 5–20 minute interval with the caregiver encouraging use of the extremity is generally sufficient to determine reduction success. If the patient does not demonstrate spontaneous movement on reassessment, a second reduction attempt with the same or alternate technique should be trialed.
Recurrence of Nursemaid's Elbow ranges between 27-39%. No long-term sequelae are associated with single or multiple presentations of this injury. Anticipatory guidance should be provided to all parents and caregivers with an emphasis on future prevention.
- Nursemaid's Elbow is very common in the toddler population.
- If clinically suspected, no radiographs are needed for diagnosis.
- Two equivalent techniques can be used for reduction - hyperpronation and supination/flexion.
- In the absence of a clear history of axial traction or with an unwitnessed event, a careful consideration should be given to the potential for fracture and diagnostic imaging may be indicated.
- Bachman D. Orthopedic Trauma: Textbook of Pediatric Emergency Medicine, 5th edition. Lippincott Williams and WIlkins. 2006.
- Johnson FC, Okada PJ. Reduction of Common Joint Dislocations and Subluxations. Textbook of Pediatric Emergency Procedures, 2nd edition. Lippincott Williams and Wilkins. 2007.
- Macias CG, Bothner J. A Comparison of Supination/Flexion to Hyperpronation in the Reduction of Radial Head Subluxations. Pediatrics. 1998.
- Schunk JE. Radial head Subluxation: Epidemiology and Treatment of 87 Episodes. Annals of Emergency Medicine. 1990.