Pediatrics, Nursemaid Elbow Treatment & Management

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

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.

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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 series[5] 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.
  • One abstract reports that pronation may be more effective than supination.[6] A Cochrane Database of Systemic Reviews study found limited evidence that pronation may be more effective and less painful than supination.[7]

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.

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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.

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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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