Overview
Definition:
Nursemaid's elbow, also known as radial head subluxation, is a common injury in young children characterized by the displacement of the annular ligament from around the radial head.
Epidemiology:
It most commonly occurs in children aged 1 to 5 years, with a peak incidence between 2 and 4 years old
It is rare before 6 months and after 6 years
The left arm is affected more often than the right.
Clinical Significance:
This is a common pediatric emergency that requires prompt and accurate diagnosis and management to relieve pain and restore normal elbow function
Misdiagnosis can lead to delayed treatment and potential complications.
Clinical Presentation
Symptoms:
Child typically presents with sudden onset of elbow pain
Refusal to use the affected arm
Child may hold the arm in a pronated and flexed position
Crying or irritability when the arm is touched or moved.
Signs:
Affected arm held in a characteristic position: slight flexion and pronation
Tenderness to palpation over the radial head
Swelling is usually minimal or absent
No gross deformity or crepitus
Range of motion is often limited, particularly supination.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the characteristic history and physical examination findings in a young child
Radiographs are typically normal and are not required for diagnosis but may be used to rule out fractures.
Diagnostic Approach
History Taking:
Inquire about the mechanism of injury, which usually involves traction applied to the child's arm (e.g., pulling a child up from the ground, swinging the child by the arms)
Note the onset and duration of pain
Ask about prior episodes.
Physical Examination:
Carefully examine both elbows
Assess for point tenderness over the radial head
Gently attempt passive range of motion, noting limitations, especially in supination
Avoid forceful movements that could exacerbate pain or potentially cause further injury
Observe the child's posture and arm usage.
Investigations:
Radiographs are usually not necessary for diagnosing nursemaid's elbow
If performed, they will typically be normal
X-rays are indicated if there is suspicion of a fracture (e.g., significant swelling, visible deformity, trauma mechanism suggestive of fracture, or if reduction is unsuccessful).
Differential Diagnosis:
Fracture of the radial neck or elbow
Periostitis
Cellulitis
Septic arthritis of the elbow
Transient synovitis of the hip (referred pain)
Atraumatic elbow pain.
Management
Initial Management:
The primary goal is pain relief and reduction of the radial head subluxation
No immobilization or casting is typically required after successful reduction
Analgesia may be provided.
Reduction Techniques:
Several manual reduction techniques exist: 1
**Supination-flexion method:** With the child's elbow slightly flexed, firmly supinate the forearm while simultaneously flexing the elbow
A palpable or audible click may be felt or heard
2
**Hyperpronation method:** With the elbow slightly flexed, hyperpronate the forearm
Some studies suggest this may be more effective
3
**Combined technique:** A combination of hyperpronation followed by flexion
The procedure should be gentle and performed by experienced personnel
Reassurance and distraction for the child are crucial.
Post Reduction Care:
After successful reduction, the child will usually begin using the arm spontaneously within minutes to an hour
If the child continues to refuse to use the arm, a second reduction attempt may be considered by an experienced clinician
If reduction is unsuccessful after a few attempts, orthopedic consultation is recommended
Plain radiographs may be considered to rule out occult fractures if concerns persist.
Supportive Care:
Provide clear instructions to parents regarding the expected recovery and signs of complications
Reassurance that this is a benign condition with a good prognosis.
Complications
Early Complications:
Failure of reduction
Re-subluxation (can occur if the child falls or is pulled again).
Late Complications:
Rarely, persistent pain or stiffness if not properly managed or if a fracture was missed
No long-term sequelae are expected with appropriate management.
Prevention Strategies:
Avoid pulling a young child by their hands or forearms
Do not swing children by their arms
Educate parents and caregivers on safe handling practices for young children.
Prognosis
Factors Affecting Prognosis:
Early diagnosis and prompt, successful reduction lead to an excellent prognosis
The prognosis is generally excellent, with rapid return to full function.
Outcomes:
Most children experience immediate pain relief and full use of the arm after successful reduction
Recurrence is uncommon.
Follow Up:
Follow-up is generally not required unless symptoms persist or there is concern for re-injury
Parents should be advised to seek medical attention if the child continues to have pain or inability to use the arm after the initial management.
Key Points
Exam Focus:
Recognize the typical age group (1-5 years) and mechanism of injury (longitudinal traction)
Identify the characteristic arm position (slight flexion and pronation)
Understand the primary reduction techniques (supination-flexion and hyperpronation)
Know that radiographs are usually normal.
Clinical Pearls:
A gentle, confident approach is key for reduction
Distraction techniques are invaluable
Palpable click is reassuring but not always present
If reduction fails, reassess for fracture or seek senior help rather than repeated forceful attempts.
Common Mistakes:
Over-reliance on X-rays when the diagnosis is clinical
Forgetting to assess for fracture in the presence of significant tenderness or deformity
Attempting aggressive reduction without adequate distraction or expertise
Failing to reassure parents about the benign nature of the condition.