Nursemaid's Elbow

Background

Nursemaid's elbow (also termed radial head subluxation, pulled elbow and annular ligament displacement) is a common injury that is seen most often in children between the ages of 1-4 years.  Usually, the child has had an incident in which the extended arm was pulled.  Most commonly, it occurs when a child is falling and the individual holding the hand doesn't let go.  Another common mechanism is when the child is swinging while being held by the hands.  Occasionally, the injury occurs after a fall. 

Anatomy and Pathology

Nursemaids elbow is an interposition of the annular ligament into the radial-humeral joint.  The annular ligament normally passes around the proximal radius just below the radial head.  With traction on the extended arm, the annular ligament slides over the head of the radius into the joint space and becomes entrapped.  Symptoms are a result of the displacement of the annular ligament.

Epidemiology

  1. Nursemaid’s elbow is the most common elbow injury in young children.
  2. More common in girls than boys and more often on the left side.
  3. Usually between 1-4 years of age (peak incidence 2-3) and rare after age 4.

Clinical Presentation

  1. Usually presents with child not using affected arm and holding it flexed and pronated.
  2. There is usually a history of axial traction often times caused by a caregiver grabbing a child’s arm or swinging child.  Infants may also present with dislocation after rolling over on arm.  Occasionally, this history is not present.
  3. Tenderness may be elicited over the elbow joint but there is no swelling, redness, warmth, abrasions, or ecchymosis.

Diagnosis

  1. The diagnosis is by history and physical examination. Radiograph examination is usually not necessary and are normal in most instances. Often, during the taking of the x-ray, the subluxation is reduced when the technician positions the arm on the plate.

Treatment

  1. While supporting the radial head, the forearm is supinated or pronated and flexed at the same time.  A "click" will be heard or felt.  Recent studies suggest that pronation is less painful than supination and results in less treatment failure.
  2. Reduction is painful but quick.
  3. After the “reduction,” the child will immediately use the arm. There is no indication for immobilization and rarely are analgesics necessary. 
  4. Unless the child doesn't start to use the arm, follow-up is unnecessary.
  5. There is a relatively high incidence of recurrence (27-39%).  Parents should be made aware of this and the mechanism of injury should be explained.  It may be useful to teach the parents how to "reduce" the dislocation at home. 
  6. There are no known sequelae.

http://3.bp.blogspot.com/_i6s1W3PdB9A/SaVLh4b8u0I/AAAAAAAAA-k/8wV2IBYfhFs/s400/Picture+1.png

Image from http://3.bp.blogspot.com/_i6s1W3PdB9A/SaVLh4b8u0I/AAAAAAAAA-k/8wV2IBYfhF...

Click Here for a video demonstrating both techniques.

References

  1. Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. American Journal of Diseases of Children 1985; 139:1194.
  2. Choung, Walter, and Heinrich,Stephen. Acute Annunlar Ligament Interposition into the Radiocapitellar Joint in Children (Nursemaid's Elbow). Journal of Pediatric Orthopedics. Vol. 15, No.4 1995
  3. Waander, Hellerstein, and Ballock. Nursemaid's Elbow, Pulling out the Diagnosis  Contemporary Pediatrics June 2000
  4. Macias CG, Wiebe R, Bothner J. History and radiographic findings associated with clinically suspected radial head subluxations. Pediatr Emerg Care 2000; 16:22.
  5. Krul M, van der Wouden JC, van Suijlekom-Smit LWA, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Systemic Revew. 2012;1:CD0077

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