Nursemaid’s elbow occurs when the radius (one of the bones in the forearm) slips out of place from where it normally attaches to the elbow joint. It is a common condition in children younger than 4 years of age it can cause a condition known as a nursemaid’s elbow or subluxation of the radial head. It happens when a baby’s ligaments get loose, slip, and then get trapped between the joints. It is also called pulled elbow, slipped elbow, or toddler’s elbow. Face the child and hold the affected elbow in the palm of one hand, placing your thumb over the radial head. Hold the wrist in your other hand, with your thumb and fingers on opposite sides of the wrist. Explain to the caregiver that the technique will cause transient pain. Maintain the elbow at 90° of flexion.
Other Names
- Subluxation of the annular ligament
- Subluxation of the radial head
- Pulled Elbow
Pathophysiology
Illustration of Nursemaid’s Elbow
- General
- Sudden traction at the hand or wrist leading to the pronated forearm and extended elbow
- Can also occur after a minor fall
- Reported in infants who roll over on their arm, trapping underbody while sleeping
Causes
- The annular ligament becomes interposed into the Radiocapitallar Joint, between the radial head and Capitellum
- In older children (i.e. 5+), thickened, stronger distal attachment of annular ligament prevents subluxation
- Annular Ligament
- Strong, circular ligamentous band that anchors the Radius to the radial notch of the Ulna
- Fractures
- Adult
- Radial Head Fracture
- Olecranon Fracture
- Capitellum Fracture
- Coronoid Fracture
- Terrible Triad of Elbow
- Pediatric
- Nursemaids Elbow
- Supracondylar Fracture
- Lateral Condyle Fracture (Peds)
- Medial Condyle Fracture (Peds)
- Olecranon Fracture (Peds)
- Radial Head Fracture (Peds)
- Medial Epicondyle Fracture (Peds)
- Salter Harris Fracture
- Adult
- Dislocations & Instability
- Elbow Dislocation
- Proximal Radioulnar Joint Instability
- Tendinopathies
- Lateral Epicondylitis
- Medial Epicondylitis
- Distal Biceps Tendon Injury
- Triceps Tendon Injury
- Bursopathies
- Olecranon Bursitis
- Ligament Injuries
- Lateral Collateral Ligament Injury (Elbow)
- Ulnar Collateral Ligament Injury
- Neuropathies
- Cubital Tunnel Syndrome
- Radial Tunnel Syndrome
- Arthropathies
- Elbow Arthritis
- Other
- Valgus Extension Overload
- Posteromedial Rotatory Instability
- Posterolateral Rotatory Instability
- Osteochondral Defect
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
Diagnosis
- History
- The mechanism will generally involve a traction force on the affected extremity
- The parent may report a click during the episode
- The child will refuse to move his arm, holds their elbow in flexion and pronation
- Physical: Physical Exam Elbow
- Pain, tenderness to lateral elbow
- Flexion and extension intact
- Pain when the supinating forearm
- Special Tests
Radiographs
- Primary a clinical diagnosis, is helpful to exclude other etiologies
- Imaging is not required if the story fits the classic presentation
- Standard Radiographs Elbow
- Typically normal when obtained
- May demonstrate radiocapitellar line slightly lateral to center of capitellum
- Consider imaging if significant MOI, ecchymosis, swelling, age > 5, difficult reduction
Ultrasound
- May be used to help confirm the diagnosis (need citation)
Treatment
Hyper pronation Technique (Moving hand toward thumbs down position)
- Hold the child’s hand as if you are going to give him or her a handshake.
- Support the elbow with your other hand.
- Move the hand toward the thumb facedown.
- When you feel or hear a click, the elbow is reset.
- Pain should subside and movement should return.
Nonoperative
- Indications
- First line in virtually all cases
- The majority of cases are managed nonoperatively
- Hyperpronation Technique
- Recommended first line technique due to higher first attempt success rate[4]
- Examiner supports elbow flexed to 90°, applies moderate pressure with finger at the radial head
- Hyperpronate the patients forearm with other hand
- Supination & Flexion Technique
- Physician places thumb over radial head
- Hold patients arm in supination
- Apply maximum flexion
- Physician will likely heal a palpable click with reduction of the radial head
- Post reduction
- Child typically has full range of motion within 10-30 minutes
- Will begin spontaneously moving affected arm
- Can challenge with item of interest (i.e. bottle, popsicle, etc)
- If unsuccessful reduction, recommend obtain radiographs and consider alternative diagnosis
Operative
- Indication
- Chronic, symptomatic subluxations that will not maintain stable reduction
- Technique
- Open Reduction
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