eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Nursemaid Elbow

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Devin N Boss, DO, Attending Physician, Department of Emergency Medicine, St John's Clinic

Updated: Jul 7, 2009

Introduction

Background

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

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.

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

Clinical

History

Patient history usually leads to a presumptive diagnosis.

Parents often give a history of a young child with no history of trauma who suddenly refuses to use an arm.
A history of axial traction by a pull on the hand or wrist may be elicited but often is not volunteered.
Common scenarios include the following:
- A toddler held by his or her hand who has the hand pulled as the child and adult lurch in opposite directions.
- A toddler is pulled by the wrist up and over an obstacle.
- An arm is pulled through the sleeve of a sweater or coat.
The condition is usually unilateral. However, bilateral cases have been reported.

Physical

Physical examination commonly reveals an anxious child who is protective of the affected arm.
In most children, anxiety is greater than pain.
The forearm is usually flexed 15-20 degrees at the elbow, and the forearm is partially pronated.
Often, the weight of the affected arm is supported with the other hand.
Erythema, warmth, edema, or signs of trauma are absent.
Distal circulation, sensation, and motor activity are normal. A reluctance to move digits or the wrist is common, probably from fear of eliciting pain in the elbow.
Tenderness at the head of the radius may be present.
The patient resists supination/pronation as well as flexion/extension of the forearm.

Causes

Axial traction is the most common cause of nursemaid elbow.
A fall is the second most common mechanism of injury.
Infants have been reported with nursemaid elbow after rolling over or being assisted to roll over.

Differential Diagnoses

Fractures, Elbow
Fractures, Wrist
Hand Injury, Soft Tissue

Workup

Imaging Studies

Imaging studies are useful in ruling out possible fracture but are often unnecessary.
If manipulation is unsuccessful and a review of the history and physical examination supports nursemaid elbow as the likely diagnosis, another attempt at reduction is warranted.
If reduction is unsuccessful after 2-3 attempts, radiography of the extremity is warranted.
Ultrasonography has been used as a noninvasive modality to assess for annular ligamentous injury and displacement of the radial head from the capitellum. It has also been used to assess progress of treatment for patients with recurrent subluxations. Usefulness in the acute setting is the subject of continued investigation.^3,4
MRI can be used to confirm subluxation with a ligament tear.³

For additional information, see Elbow Trauma, Pediatric and Elbow, MRI.

Treatment

Prehospital Care

"First do no harm" is a useful precept for prehospital care. Assume that a fracture is present. Taking appropriate precautions to immobilize and protect the extremity is usually wise.

Emergency Department Care

"First do no harm" is also a useful precept to follow in the ED.

Because normal function can be quickly restored in the ED, this is a gratifying condition for the physician to treat.
Treatment consists of manipulating the child's arm so that the annular ligament and radial head return to their normal anatomic positions.
- This is accomplished by immobilizing the elbow and palpating the region of the radial head with one hand.
- The other hand applies axial compression at the wrist while supinating the forearm and flexing the elbow.
- As the arm is manipulated, a click or snap can be felt at the radial head.
A click noted by the examiner has a positive predictive value of more than 90% in 2 published case series⁵ and a negative predictive value of 76% in one case series.¹
Some authors believe the likelihood of successful reduction is increased if pressure is applied over the radial head.
- Nursemaid elbow can be reduced by extension of the forearm instead of flexion; however, extension was less effective in achieving reduction in one case series.
- A recent abstract reports that pronation may be more effective than supination.⁶
If manipulating the elbow produces a click, the child should be observed in the ED. Many references report immediate return of function, but often the child will not use the arm normally for 15-30 minutes.
If radiographic findings reveal no fracture and the child continues to refuse to use the arm normally, another attempt at reduction (ideally, by a different health professional, if available) is reasonable. Age younger than 2 years and a delay of more than 4 hours before treatment have been associated with failure to use an affected arm within 30 minutes.
If manipulation is successful and the child regains normal use of the arm in the ED (the usual clinical scenario), discharge is warranted. Postreduction films are not necessary.
An important part of the management is educating parents about the risk of reoccurrence.

Consultations

If radiographic findings demonstrate no fracture, repeat attempts at reduction are unsuccessful, and the child does not regain normal function after 30-40 minutes, the safest management is to support the arm in a sling (or splint and sling) and have the child reevaluated by a physician (usually a primary care physician, not an orthopedist) in 1-2 days. One case series reported 7 patients meeting these criteria had either spontaneous return of function or successful reduction at follow-up evaluation by day 4.

Medication

Once reduced, pain abates, and further therapy is unnecessary. Persistent pain is inconsistent with nursemaid elbow and should lead one to reconsider the diagnosis.

Follow-up

Deterrence/Prevention

Because nursemaid elbow tends to reoccur, families benefit from counseling. Avoidance of future axial traction should minimize risk of reoccurrence.

Prognosis

The prognosis is excellent. Parents can be reassured that no permanent injury results from this condition.
For those who have had one occurrence, the chance of recurrence is approximately 20-25%.^1,4,7 Those 24 months and younger may have the greatest risk of recurrence.⁷

Miscellaneous

Medicolegal Pitfalls

The primary concern is to make an accurate presumptive diagnosis by obtaining a careful history and physical examination.
- If reasonable doubt surrounds the diagnosis, performing radiography of the extremity before attempting reduction is prudent to avoid manipulation of an extremity with an elbow fracture.
- If pain persists after attempted reduction, reconsider the diagnosis. Reduction of nursemaid elbow normally produces prompt cessation of pain and prompt return of full function.
Consider wrist or shoulder pathology in patients with uncertain diagnosis.

References

Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med. Sep 1990;19(9):1019-23. [Medline].
Pearson BV, Kuhns DW. Nursemaid's elbow in a 31-year-old female. Am J Emerg Med. Feb 2007;25(2):222-3. [Medline].
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].
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].
Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child. Dec 1985;139(12):1194-7. [Medline].
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].
Teach SJ, Schutzman SA. Prospective study of recurrent radial head subluxation. Arch Pediatr Adolesc Med. Feb 1996;150(2):164-6. [Medline].
Frumkin K. Nursemaid's elbow: a radiographic demonstration. Ann Emerg Med. Jul 1985;14(7):690-3. [Medline].
Griffith ME. Subluxation of the head of the radius in young children. Pediatrics. 1955;103-6.
Kaplan RE, Lillis KA. Recurrent nursemaid's elbow (annular ligament displacement) treatment via telephone. Pediatrics. Jul 2002;110(1 Pt 1):171-4. [Medline].
Michaels MG. A case of bilateral nursemaid's elbow. Pediatr Emerg Care. Dec 1989;5(4):226-7. [Medline].
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].
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].
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].
Stone CA. Subluxation of the head of the radius. JAMA. 1916;67:28-9.
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].
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.

Keywords

nursemaid elbow, nurse maid elbow, nursemaid's elbow subluxed radial head, toddler's elbow, pulled elbow, slipped elbow, annular ligament displacement, Malgaigne luxation, Malgaigne's luxation, elbow fracture, elbow dislocation, dislocated elbow treatment, dislocated elbow causes

Contributor Information and Disclosures

Author

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
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.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

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.

CME Editor

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.

Further Reading