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Nursemaid Elbow Workup

  • Author: Wayne Wolfram, MD, MPH; Chief Editor: Kirsten A Bechtel, MD  more...
 
Updated: Feb 07, 2016
 

Approach Considerations

The primary challenge is to arrive at the correct diagnosis without overlooking other causes of the patient's symptoms.

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Imaging Studies

In nursemaid’s elbow, the annular ligament becomes transiently interposed between the radial head and capitellum, but does not cause recognizable widening of the radiocapitellar joint. Nursemaid’s elbows are often indistinguishable from healthy elbows on radiograph.[3]  However, if  history and/or physical exam reveal concerns for possible fracture, radiography may be warranted.

If manipulation is unsuccessful and a review of the history and physical examination supports nursemaid elbow as the likely diagnosis, another attempt at reduction may be performed using the same method. If reduction is again unsuccessful, a third attempt using the alternative technique may be utilized. If a third attempt at reduction fails, radiography of the extremity is warranted to look for fracture (if not already done).

Ultrasonography has been used as a noninvasive modality to evaluate annular ligament injury. Published reports describe increased radiocapitellar distance, representing annular ligament entrapment prior to manipulation.[9, 10]  Other ultrasound findings include a “J-shaped” hypoechoic supinator muscle, or “Hook” sign above the radial head.[11, 12] It should be noted that ultrasound can also be used to assess for fractures. An enlarged posterior fat pad or lipohemarthrosis in the olecranon fossa are findings associated with fracture.[13] A negative ultrasound may reduce the need for radiographs in children with elbow injuries.[14]

Although ultrasonography can confirm a nursemaid’s elbow, and evidence for its accuracy are emerging, utility in the acute setting is the subject of continued investigation.[15, 16]

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

 

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.[15, 16]

MRI can be used to confirm subluxation with a ligament tear.[15]

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

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Other Tests

MRI can be used to confirm subluxation with a ligament tear.[15]

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Contributor Information and Disclosures
Author

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

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

Disclosure: Nothing to disclose.

Mark Panetta, MD Resident Physician, Department of Emergency Medicine, Mercy St Vincent Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

Garry Wilkes, MBBS, FACEM Director of Clinical Training (Simulation), Fiona Stanley Hospital; Clinical Associate Professor, University of Western Australia; Adjunct Associate Professor, Edith Cowan University, Western Australia

Disclosure: Nothing to disclose.

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