Nursemaid’s Elbow

Medical Student Pearl

Erika Maxwell

Memorial University Class of 2023

Reviewed by: Dr. David Lewis

Case

A 10-month-old female is brought into the Emergency Department by her mother with a left arm injury. The infant had a fall from standing and the mother reached out to grab her and caught her left forearm. After the incident, the patient’s mother noticed that the infant was no longer using the arm. The child has no medical history and is not taking any medications. She is vitally stable.

On exam, the child’s left arm is limp and extended at her side. She is using her right arm and hand exclusively, including to grasp for items on the left side of her body (pseudoparalysis). There is no deformity, erythema, edema, or ecchymosis. The arm and hand are neurovascularly intact (strong brachial pulse, pink and warm).

Differential Diagnosis

Nursemaid’s elbow/pulled elbow/radial head subluxation
Elbow fracture
Wrist fracture or soft tissue injury
Shoulder dislocation

Background

A pulled elbow occurs most frequently in young children with the median age for presentation being 2 years [1]. The reason for this is debated in the literature with some sources saying that the annular ligament is weaker in children [2] and others saying that the radial head is smaller [1], both resulting in a less stable joint.

The most common mechanism of injury is axial traction (i.e. pulling on the arm or hand), but falls or rough play may also be responsible [2].

Anatomical Context

The annular ligament holds the radial head in place next to the ulna. When axial traction is applied by pulling the forearm or hand, the radial head may move underneath the annular ligament and trap it in the radiohumeral joint, against the capitellum [1].

Figure 1: The arm on the left displays a normal elbow, whereas on the right the radius is subluxated and trapping the annular ligament against the capitellum [3].

Signs and Symptoms [3]

Pain at elbow
Pseudoparalysis of injured arm
Extension or light flexion of injured arm, often pronated

Diagnosis and Management

A full examination of the upper limb is required. Leave obviously swollen or deformed areas until the end. Palpate the clavicle, humerus, forearm and gently move the joints (shoulder, wrist, and lastly elbow). Pulled elbows rarely result in joint swelling. If this is present an alternative diagnosis should be considered (e.g., supracondylar fracture).

If a pulled elbow is the only likely diagnosis, then it may be reasonable to proceed to a subluxated radial head reduction manoeuvre. However, when the history is not clear (e.g., unwitnessed mechanism involving siblings or a fall), then it is much safer to perform further diagnostic tests prior to manipulation. These include radiograph of the elbow to rule out fracture or elbow ultrasound to rule out joint effusion [4].

Reduction Technique

This is done by supporting the elbow with one hand and using your other hand to move the patient’s arm through the recommended maneuvers. There are 2 different maneuvers to try, and they may be used alone or in combination [1-3,5].

Supinate the child’s forearm with your hand and flex the elbow

Figure 2: Demonstration of the supination/flexion maneuver [5]

Hyperpronate the child’s forearm

Figure 3: Demonstration of the hyperpronation maneuver [5]

Some research has indicated that the hyperpronation maneuver may be more effective and less painful for the patient [2,6], so it may be worth attempting this maneuver first.

If the maneuvers are successful, you may hear a click from the radial head as it moves back into place. The child may briefly cry as the subluxation is reduced. Movement recovery can take anywhere from a few minutes to several hours, but usually occurs within 30 minutes. The greater the delay from injury to presentation and subsequent reduction, the longer it will take for post reduction return to normal movement [2].

If a click is heard or felt during the manoeuvre it can usually be assumed that reduction has occurred. Ideally, it is recommended that the child remain under observation until normal movement returns. However, if delayed, it is reasonable to discharge the child with advice to return.

In any case where an x-ray or ultrasound has not been performed and the child does not rapidly start using their arm post manoeuvre, then imaging is required prior to any further manipulation.

Prognosis

Although a pulled elbow does not result in a permanent injury, it is important to inform the family that their child will be vulnerable to recurrent pulled elbows in the affected arm. Up to 27% of patients with a pulled elbow may experience a recurrence [7-8].

Case continued:

Based on the patient’s history and physical exam, she was diagnosed with a pulled elbow. Using the supination and flexion maneuver followed by the hyperpronation maneuver, an audible click was elicited from the patient’s elbow. Shortly thereafter, she began using the arm again as if no injury had occurred and was discharged home.

Key points:

A pulled elbow is a common upper limb injury in young children presenting to the Emergency Department
Careful assessment may preclude the need for diagnostic imaging however if in any doubt further investigation should be performed prior to manipulation. Many physicians will never forget the time they used a pulled elbow reduction technique in a child with an unexpected supracondylar fracture
HYPERPRONATE and/or SUPINATE & FLEX!
Recurrence is common

References

Aylor, M., Anderson, J., Vanderford, P., Halsey, M., Lai, S., & Braner, D. A. (2014). Reduction of pulled elbow. New England Journal of Medicine, 371(21), e32.
Wolfram, W., Boss, D., & Panetta, M. (2018, December 18). Nursemaid Elbow. Medscape. Retrieved September 6, 2022, from https://emedicine.medscape.com/article/803026-overview#a5
Boston Children’s Hospital. (2021). Nursemaid’s elbow. Retrieved September 6, 2022, from https://www.childrenshospital.org/conditions/nursemaids-elbow
Varga, M., Papp, S., Kassai, T., Bodzay, T., Gáti, N., & Pintér, S. (2021). Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow. Injury, 52(1), S21-24.
Kilgore, K., & Henry, K. (2021). Nursemaid’s elbow. Society for Academic Emergency Medicine – Clerkship Directors in Emergency Medicine. Retrieved September 6, 2022, from https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/peds-em-curriculum/nursemaid%27s-elbow
Lewis, D., Argall, J., & Mackway-Jones, K. (2003). Reduction of pulled elbows. Emergency Medicine Journal, 20, 61-62.
Schunk, J. F. (1990). Radial head subluxation: epidemiology and treatment of 87 episodes. Annals of emergency medicine, 19(9), 1019-1023.
Teach, S. J., & Schutzman, S. A. (1996). Prospective study of recurrent radial head subluxation. Archives of pediatrics & adolescent medicine, 150(2), 164-166.