Nursemaid Elbow Treatment & Management

Updated: Dec 18, 2018
  • Author: Wayne Wolfram, MD, MPH; Chief Editor: Kirsten A Bechtel, MD  more...
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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.

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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 can be a gratifying condition for the physician to treat.

Treatment consists of manipulating the child's arm (closed reduction) so that the annular ligament and radial head return to their normal anatomic positions. Traditionally, the manipulation consists of forearm supination and elbow flexion, as follows:

  • 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 may 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 [19] and a negative predictive value of 76% in one case series. [4]

Some authors believe the likelihood of successful reduction is increased if pressure is applied over the radial head.

Reports describe successful closed reduction using forearm hyper-pronation (HP) instead of supination-flexion (SF) Pronation may be more effective and/or less painful than supination manipulation. [20, 21, 22, 23, 33] A recent prospective, pseudorandomized, controlled non-blinded study compared the efficacy and pain associated with HP and SF reduction techniques. Successful reduction was accomplished on first attempt in 121(80.7%) of cases, with 56 of 82(68.3%) using the SF technique and 65 of 68 (95.6%) using the HP technique (P< 0.001). However, pain levels of both techniques were not statistically different. [24]   The findings are corroborated by two other randomized, prospective studies that found significantly higher rates of first-attempt success with the HP technique. [25, 26]

Videos are available online showing both forearm SF and HP techniques. [27, 28] A quick overview of the disorder and the reduction maneuvers is also available for free through the NEJM website. [29]

A 2012 Cochrane Collaboration review noted that the total number of patients assessed in all of these studies was small. Furthermore, all studies were at high risk for assessor bias due to lack of blinding of the assessors. One study was assessed to be at high risk for selection bias. The conclusion was that evidence is limited for low-quality clinical trials and further study is warranted. [30]

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. Given that intra-operator variability is not always reported and one may become comfortable with one technique or the other, it is reasonable to make first and second attempts at reduction with either method.

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 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.

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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