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Emergency and Acute Medicine – Nursemaid’s Elbow
Nursemaid’s elbow is the most common elbow injury in children younger than five years of age. It occurs when sudden longitudinal traction is applied to the distal radius, causing the annular ligament to slip over the radial head and become interposed between the radius and the capitellum. Typical mechanisms include lifting or pulling a child by the hands or arms, swinging the child during play, wrestling, or abrupt traction during a fall. In infants younger than six months, the injury may occur when the child rolls onto the arm. By approximately five years of age, the annular ligament becomes thicker and more resistant to displacement, making this injury uncommon in older children.
Children with nursemaid’s elbow classically refuse to use the affected arm. The elbow is usually held slightly flexed, with the forearm pronated and close to the trunk. Pain is noted with elbow flexion and particularly with forearm supination or pronation. There is typically minimal or no swelling and no obvious deformity. Point tenderness is absent or limited to mild tenderness over the anterolateral radial head. Passive range of motion is usually painless, but the child avoids active use of the arm. Although a history of pulling on the arm is characteristic, it is reported in only about half of cases, and alternative mechanisms such as minor trauma or twisting injuries should be considered.
The diagnosis of nursemaid’s elbow is clinical and relies on a classic history and physical examination findings. Routine imaging is not required. Radiographs should be obtained if there is focal bony tenderness, soft tissue swelling, deformity, ecchymosis, an atypical history, failed reduction attempts, or persistent refusal to use the arm after reduction. The differential diagnosis includes fractures of the humerus, radius, or ulna, elbow dislocation, septic arthritis, osteomyelitis, and rarely neoplasm.
Prehospital care consists of placing ice on the elbow to reduce discomfort, immobilizing the arm in a sling or splint for transport, and assessing distal neurovascular status. In the emergency department, initial stabilization includes confirmation of intact distal motor, sensory, and vascular function before attempting reduction.
Definitive treatment is reduction of the radial head subluxation. Two reduction techniques are commonly used. The supination–flexion technique involves gentle axial traction while supinating the forearm, followed by smooth flexion of the elbow, with the examiner’s thumb applying pressure over the radial head. The hyperpronation technique involves gentle axial traction with forceful hyperpronation of the forearm, with extension if the arm is not already extended, again stabilizing the radial head. Hyperpronation is generally more successful and is often perceived as less painful by caregivers. A subtle click may be palpated during successful reduction. The child may cry briefly during the maneuver but often resumes normal use of the arm within minutes. If the child does not use the arm within 15 minutes, a second reduction attempt should be performed, preferably using the alternate technique. Failure after two attempts warrants radiographic evaluation.
Medications are usually unnecessary, as pain resolves rapidly after successful reduction. If needed, acetaminophen or ibuprofen may be given for comfort. There are no admission criteria for uncomplicated nursemaid’s elbow. Children may be discharged once they regain full, unrestricted use of the arm. Parents should be counseled to avoid lifting or pulling the child by the hands, wrists, or forearms. Recurrence is common, with rates of approximately 27–39%, until the child reaches five years of age.
Follow-up is not required after successful reduction. If reduction is unsuccessful and imaging is negative for fracture, orthopedic referral is recommended, and the arm should be placed in a sling or posterior splint for outpatient evaluation. Key pearls include maintaining suspicion with a classic presentation, avoiding unnecessary radiographs, ensuring that at least one reduction attempt uses the hyperpronation technique, and recognizing that short delays in reduction do not result in long-term sequelae.
Nursemaid’s elbow is the most common elbow injury in children younger than five years of age. It occurs when sudden longitudinal traction is applied to the distal radius, causing the annular ligament to slip over the radial head and become interposed between the radius and the capitellum. Typical mechanisms include lifting or pulling a child by the hands or arms, swinging the child during play, wrestling, or abrupt traction during a fall. In infants younger than six months, the injury may occur when the child rolls onto the arm. By approximately five years of age, the annular ligament becomes thicker and more resistant to displacement, making this injury uncommon in older children.
Children with nursemaid’s elbow classically refuse to use the affected arm. The elbow is usually held slightly flexed, with the forearm pronated and close to the trunk. Pain is noted with elbow flexion and particularly with forearm supination or pronation. There is typically minimal or no swelling and no obvious deformity. Point tenderness is absent or limited to mild tenderness over the anterolateral radial head. Passive range of motion is usually painless, but the child avoids active use of the arm. Although a history of pulling on the arm is characteristic, it is reported in only about half of cases, and alternative mechanisms such as minor trauma or twisting injuries should be considered.
The diagnosis of nursemaid’s elbow is clinical and relies on a classic history and physical examination findings. Routine imaging is not required. Radiographs should be obtained if there is focal bony tenderness, soft tissue swelling, deformity, ecchymosis, an atypical history, failed reduction attempts, or persistent refusal to use the arm after reduction. The differential diagnosis includes fractures of the humerus, radius, or ulna, elbow dislocation, septic arthritis, osteomyelitis, and rarely neoplasm.
Prehospital care consists of placing ice on the elbow to reduce discomfort, immobilizing the arm in a sling or splint for transport, and assessing distal neurovascular status. In the emergency department, initial stabilization includes confirmation of intact distal motor, sensory, and vascular function before attempting reduction.
Definitive treatment is reduction of the radial head subluxation. Two reduction techniques are commonly used. The supination–flexion technique involves gentle axial traction while supinating the forearm, followed by smooth flexion of the elbow, with the examiner’s thumb applying pressure over the radial head. The hyperpronation technique involves gentle axial traction with forceful hyperpronation of the forearm, with extension if the arm is not already extended, again stabilizing the radial head. Hyperpronation is generally more successful and is often perceived as less painful by caregivers. A subtle click may be palpated during successful reduction. The child may cry briefly during the maneuver but often resumes normal use of the arm within minutes. If the child does not use the arm within 15 minutes, a second reduction attempt should be performed, preferably using the alternate technique. Failure after two attempts warrants radiographic evaluation.
Medications are usually unnecessary, as pain resolves rapidly after successful reduction. If needed, acetaminophen or ibuprofen may be given for comfort. There are no admission criteria for uncomplicated nursemaid’s elbow. Children may be discharged once they regain full, unrestricted use of the arm. Parents should be counseled to avoid lifting or pulling the child by the hands, wrists, or forearms. Recurrence is common, with rates of approximately 27–39%, until the child reaches five years of age.
Follow-up is not required after successful reduction. If reduction is unsuccessful and imaging is negative for fracture, orthopedic referral is recommended, and the arm should be placed in a sling or posterior splint for outpatient evaluation. Key pearls include maintaining suspicion with a classic presentation, avoiding unnecessary radiographs, ensuring that at least one reduction attempt uses the hyperpronation technique, and recognizing that short delays in reduction do not result in long-term sequelae.
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