Pediatrics, Nursemaid Elbow 

  • Author: Wayne Wolfram, MD, MPH; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Dec 7, 2010
 

Background

Nursemaid elbow is a common and easily treated condition. Correct diagnosis is the primary challenge to the physician.

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Pathophysiology

The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn.

As children age, the annular ligament strengthens, making the condition less common. The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm. The common belief that nursemaid elbow is due to children having a radial head smaller than the radial neck is incorrect.

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Epidemiology

Sex

Published case series report a slight predominance in females.[1]

Published case series report a slight left arm predominance in both males and females.[1]

Age

Nursemaid elbow most commonly occurs in children aged 1-4 years. However, it has been reported in patients as young as 4 months and as old as 31 years.[2]

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Contributor Information and Disclosures
Author

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Devin N Boss, DO  Attending Physician, Department of Emergency Medicine, St John's Clinic

Devin N Boss, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Garry Wilkes, MBBS, FACEM  Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Consultant, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Grace M Young, MD  Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

References

  1. Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med. Sep 1990;19(9):1019-23. [Medline].

  2. Pearson BV, Kuhns DW. Nursemaid's elbow in a 31-year-old female. Am J Emerg Med. Feb 2007;25(2):222-3. [Medline].

  3. Shabet S, Folman Y, Mann G, Kots Y, Fredman B, Banian M, et al. The role of sonography in detecting radial head subluxation in a child. Case Report. J Clinical Ultrasound. May 2005;33(4):187-9. [Medline].

  4. Moon KC, Eckhardt BP, Craig C, Kuhns, LR. Ultrasonography of the annular ligament partial tear and recurrent "pulled elbow." Case Report. Pediatr Radiol. Dec 2004;34(12):999-1004. [Medline].

  5. Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child. Dec 1985;139(12):1194-7. [Medline].

  6. Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. Jul 1998;102(1):e10. [Medline].

  7. Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2009;(4):CD007759. [Medline].

  8. Teach SJ, Schutzman SA. Prospective study of recurrent radial head subluxation. Arch Pediatr Adolesc Med. Feb 1996;150(2):164-6. [Medline].

  9. Frumkin K. Nursemaid's elbow: a radiographic demonstration. Ann Emerg Med. Jul 1985;14(7):690-3. [Medline].

  10. Griffith ME. Subluxation of the head of the radius in young children. Pediatrics. 1955;103-6.

  11. Kaplan RE, Lillis KA. Recurrent nursemaid's elbow (annular ligament displacement) treatment via telephone. Pediatrics. Jul 2002;110(1 Pt 1):171-4. [Medline].

  12. Michaels MG. A case of bilateral nursemaid's elbow. Pediatr Emerg Care. Dec 1989;5(4):226-7. [Medline].

  13. O'Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect. 2003;52:113-34. [Medline].

  14. Ring D, Hannouche D, Jupiter JB. Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow. J Hand Surg [Am]. May 2004;29(3):470-80. [Medline].

  15. Salter RB, Zaltz C. Anatomic investigations of the mechanism of injury and pathologic anatomy of "pulled elbow" in young children. Clin Orthop Relat Res. 1971;77:134-43. [Medline].

  16. Stone CA. Subluxation of the head of the radius. JAMA. 1916;67:28-9.

  17. Toupin P, Osmond MH, Correll R, Plint A. Radial head subluxation: how long do children wait in the emergency department before reduction?. CJEM. Sep 2007;9(5):333-7. [Medline].

  18. Van Arsdale WH. On subluxation of the head of the radius in children with a resume of one hundred consecutive cases. Ann Surg. 1889;9:401-23.

 
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