Nursemaid Elbow

Nursemaid elbow (radial head subluxation, pulled elbow) is a partial displacement of the radial head from the annular ligament, caused by sudden longitudinal traction on the extended pronated forearm of a young child.

• It occurs in children aged 1 to 4 years, peak 2 to 3 years, and is slightly commoner in girls and on the left side.
• The usual mechanism is a pull on the hand or wrist, such as lifting by the hand, swinging, or pulling the child up from a fall. Some occur after a roll in bed or a minor fall.
• The annular ligament slips over the radial head, which is still relatively small and conical in young children, and becomes entrapped in the radiohumeral joint.
• Recurrence is common (about 20 to 30 percent).
• Very rare after age 6 to 7 years.

The child is distressed briefly, then is pain-free if the arm is still.

• Child holds the arm limp by the side, slightly flexed at the elbow and pronated, and refuses to use it.
• Crying at the time of the injury, then little distress at rest.
• No swelling, deformity or bruising.
• Tenderness at the radial head or lateral elbow; pain on supination of the forearm.
• Child may move fingers and wrist normally.
• Differential diagnosis: supracondylar fracture, radial head or neck fracture, clavicle fracture, forearm fracture, septic arthritis, osteomyelitis, soft tissue injury and non-accidental injury.
• Complications: recurrence, and rarely failed reduction with ongoing pain.

Diagnosis is clinical, with no imaging if the history and signs are typical.

• Typical history of traction with no swelling or deformity.
• X-ray is not needed when the history is classic and examination is typical. Take X-rays if there is a fall, swelling, bruising, bony tenderness, deformity, atypical presentation, or failure of reduction.
• Ultrasound can confirm the diagnosis where available.
• Consider non-accidental injury in the absence of a plausible mechanism, repeated episodes or inconsistent history.

Reduction relieves the pain immediately.

• Supportive: give simple analgesia if needed (paracetamol 15 mg/kg or ibuprofen 5 to 10 mg/kg). Keep the child calm, seated on the parent's lap.
• Procedures: hyperpronation method (preferred): support the elbow with one hand, with the thumb over the radial head; with the other hand, hold the child's wrist and hyperpronate the forearm firmly; a click may be felt. Supination-flexion method: support the elbow, supinate the forearm fully and flex the elbow, pressing on the radial head.
• If the first attempt fails, try the other method or repeat once.
• The child usually begins to use the arm within 5 to 15 minutes. If the arm is not used after 15 to 30 minutes of observation, repeat or obtain an X-ray to exclude fracture.
• Aftercare: no splint or sling is necessary after successful reduction. Advise parents to avoid pulling or lifting the child by the hands or wrists.
• Special groups: children with failed reduction, recurrent episodes or suspicious injuries need further assessment. If more than 12 to 24 hours since injury, reduction is less successful and X-ray is advisable.
• Red flags: swelling, bruising, deformity, fall with significant trauma, fever, persistent refusal to use the arm after reduction and recurrent unexplained episodes.
• Follow-up: none if the child uses the arm normally. Return if the arm is not used or pain continues. Refer to orthopaedics for recurrent subluxations.