Nursemaid's elbow

Background

• Radial head subluxation due to longitudinal traction on arm
  • Annular ligament of radius displaces into radiocapitellar articulation
• Age 1y-5y (peak 2y-3y)

Clinical Features

• Sudden onset of pain and unwillingness to use affected elbow/arm
• Typical history = sudden pull on extended arm (e.g. swinging the child by arms while playing, pulling child back from walking into intersection, etc)
• Generally there is no edema, focal tenderness, or bruising

Differential Diagnosis

Elbow Diagnoses

Radiograph-Positive

• Radial head fracture
  • Essex-Lopresti fracture
• Capitellum fracture
• Olecranon fracture
• Elbow dislocation

Radiograph-Negative

• Lateral epicondylitis
• Medial epicondylitis
• Olecranon bursitis (nonseptic)
• Septic bursitis
• Biceps tendon rupture/dislocation

Pediatric

• Nursemaid's elbow
• Supracondylar fracture
• Lateral epicondyle fracture
• Medial epicondyle fracture
• Olecranon fracture
• Radial head fracture
• Salter-Harris fractures

Evaluation

• Generally clinical diagnosis
• Imaging not required before attempting reduction

Management

Reduction

Hyperpronation has greater first try success rate (94% vs 69%), but both have similar overall reduction rate; consider doing both techniques at once in quick succession

• Hyperpronation Technique
  • Hold patient's elbow at 90 degrees with one hand
  • With other hand hyperpronate patient's wrist
• Supination Technique
  • Hold patient's elbow at 90 degrees with one hand
  • With other hand supinate patient's wrist and flex elbow

Post-Reduction

• If successful patient will have return of full range of motion within 30min
• If unsuccessful after multiple attempts, obtain x-ray and consider alternative diagnoses (e.g. Salter-Harris fracture)

Disposition

• Discharge if successful reduction and return of use of arm

See Also

• Elbow diagnoses

References

Authors

Ross Donaldson, Neil Young, Jordan Swartz, Abdus Salam Khan, Michael Holtz, Ted Fan, Daniel Ostermayer, Claire