Overview
Definition:
Nursemaid's elbow, also known as a pulled elbow or annular ligament strain, is a common injury in young children characterized by the subluxation of the radial head from beneath the annular ligament
It is not a true dislocation but rather a partial displacement.
Epidemiology:
It most commonly occurs in children aged 1 to 4 years, with peak incidence between 2 and 3 years
Girls are slightly more affected than boys
The incidence is estimated to be up to 10-15% of all elbow injuries in this age group.
Clinical Significance:
Recognizing and managing nursemaid's elbow promptly is crucial to alleviate pain and prevent prolonged distress for the child
Misdiagnosis can lead to unnecessary investigations and anxiety for parents
Understanding the characteristic presentation and effective reduction techniques is vital for pediatric residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Child refuses to use the affected arm
Cries when the arm is touched or moved
Often holds the arm in slight flexion and pronation
May have a history of sudden traction on the arm
Typically no fever or systemic symptoms
May point to the elbow as the source of pain.
Signs:
Affected arm held passively by the parent or child, often supported by the unaffected arm
Palpation of the radial head may elicit pain
Minimal swelling or bruising
Normal range of motion in the elbow, but painful with supination and pronation
Tenderness may be elicited over the radial head.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on a history of sudden traction injury and characteristic physical examination findings in a child within the typical age range
There are no specific laboratory or imaging diagnostic criteria for uncomplicated nursemaid's elbow, although imaging may be used to rule out fractures in cases of uncertainty or trauma.
Diagnostic Approach
History Taking:
Key history points include how the injury occurred (e.g., being pulled up by the hand, swinging by the arms)
Ask about the exact mechanism of injury and the child's response
Inquire about any prior episodes
Red flags to identify include significant trauma, inability to move the limb at all, visible deformity, swelling, or fever, which might suggest a fracture or other serious injury.
Physical Examination:
Perform a systematic examination of the affected arm and elbow
Start with inspection for swelling, bruising, or deformity
Gently palpate for tenderness, particularly over the radial head and distal humerus
Assess the child's willingness to move the elbow and assess the range of motion passively
Assess the entire limb, including the wrist and shoulder, to rule out other injuries
Crucially, assess for pain with pronation and supination.
Investigations:
Routine investigations are usually not required for a classic presentation of nursemaid's elbow
Radiographs of the elbow may be considered if there is significant trauma, suspicion of fracture, significant swelling, or if the reduction attempt is unsuccessful and the child remains in pain
X-rays can help rule out associated fractures (e.g., torus fracture of the distal radius, buckle fracture, or supracondylar humerus fracture).
Differential Diagnosis:
Differential diagnoses include elbow fracture (e.g., buckle, torus, supracondylar), distal humerus fracture, radial head fracture, osteomyelitis, cellulitis, and trauma to other parts of the arm
The key distinguishing feature of nursemaid's elbow is the absence of significant swelling, deformity, and the typical history of traction injury with pain elicited on specific movements.
Management
Initial Management:
The primary management is closed reduction
The child should be calmed and comforted
The affected arm is often held in a pronated position with the elbow flexed.
Reduction Technique:
The most common and effective technique is hyperpronation
With the child relaxed and the elbow slightly flexed, the forearm is gently and steadily pronated while stabilizing the humerus
Alternatively, supination followed by gradual flexion can also be successful
A palpable or audible click may be felt or heard upon successful reduction
The child often immediately resumes using the arm normally.
Post Reduction:
After successful reduction, the child will typically regain full use of the arm within minutes and express relief
No casting or splinting is usually required
The child can resume normal activities
Reassurance for parents is paramount
If reduction is unsuccessful, a repeat attempt or consultation with orthopedics may be necessary.
Pharmacological Treatment:
Analgesia is generally not required after successful reduction, as the pain resolves rapidly
However, for significant initial pain or if reduction is difficult, mild analgesics like acetaminophen or ibuprofen may be considered, though their use before reduction can sedate the child and make the maneuver harder.
Complications
Early Complications:
The most common complication is failure of reduction, requiring repeat attempts or orthopedic consultation
Recurrence of subluxation is also possible if the child is pulled forcefully again
Very rarely, associated fractures might be missed if imaging is not performed.
Late Complications:
Long-term sequelae are rare
Chronic pain or stiffness is not typically associated with nursemaid's elbow
Recurrence is possible, especially in younger children, as the annular ligament may remain lax.
Prevention Strategies:
Parents and caregivers should be educated on how to avoid sudden traction on the child's arm
Avoid lifting or swinging children by their hands or forearms
Gentle handling is key.
Prognosis
Factors Affecting Prognosis:
The prognosis for nursemaid's elbow is excellent with prompt diagnosis and reduction
The main factor affecting the immediate outcome is the ease of reduction.
Outcomes:
Most children recover fully with no long-term effects
Rapid pain relief and return to normal function are expected following successful reduction
Recurrence is possible but usually easily managed.
Follow Up:
Routine follow-up is typically not required
Parents should be advised to seek medical attention if symptoms persist or recur
Education on prevention is the most important aspect of follow-up care.
Key Points
Exam Focus:
The hyperpronation technique for reduction is a high-yield topic for DNB and NEET SS pediatrics exams
Understand the typical age group, mechanism of injury, and classic presentation.
Clinical Pearls:
Always assess for pain with pronation and supination
A palpable click or immediate relief after reduction is classic
Reassurance of parents is a critical part of management
If in doubt, or if the child is very distressed or has signs of significant trauma, obtain X-rays.
Common Mistakes:
Over-investigating with X-rays in typical cases
Forgetting to try the reduction maneuver
Failing to educate parents on prevention
Misdiagnosing a fracture as nursemaid's elbow, or vice-versa.