Nursemaid's elbow

Author: Michael Hughes

Topic updated on 03/27/13 3:34pm

Introduction

Also known as subluxation of radial head
Epidemiology
- most common in children from 2 to 5 years of age.
Mechanism
- caused by longitudinal traction applied to an extended arm
Pathoanatomy
- caused by subluxation of the radial head and interposition of the annular (orbicular) ligament into the radiocapitellar joint.

Presentation

Symptoms
- a child with radial head subluxation tends to hold the elbow flexed and the forearm pronated.
Physical Exam
- pain and tenderness localized to the lateral aspect of the elbow.

Imaging

Radiographs
- radiographs are normal
- not routinely indicated in presence of classic history and physical examination

Differential

Pediatric Elbow Injury Frequency & Treatment
Fracture Type	% elbow injuries	Peak Age	Requires OR
Supracondylar fractures	41%	7	majority
Radial Head subluxation	28%	3	rare
Lateral condylar physeal fractures	11%	6	majority
Medial epicondylar apophyseal fracture	8%	11	minority
Radial Head and Neck fractures	5%	10	minority
Elbow dislocations	5%	13	rare
Medial condylar physeal fractures	1%	10	rare

Treatment

Nonoperative
- closed reduction
  - indications
    - acute cases
Operative
- open reduction
  - indications
    - chronic injuries

Techniques

Closed reduction of radial head subluxation
- reduction techniques
  - reduction is performed by manually supinating the forearm and flexing the elbow past 90 degrees of flexion.
  - while holding the arm supinated the elbow is then maximally flexed
  - during this maneuver the physician’s thumb applies pressure over the radial head and a palpable click is often heard with reduction of the radial head.
  - alternative technique includes hyperpronation of the forearm while in the flexed position.
- followup
  - immobilization is not necessary and the child may immediately resume use of the arm.
  - follow up is only needed if the child does not resume normal use of his arm in the following weeks.

Complications

Recurrence
- occurs in 5% to 39% of cases, but generally ceases after 5 years of age.

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Qbank (3 Questions)

TAG

(OBQ11.97) A 3-year-old male has decreased use of his left elbow after his mother grabbed his arm and attempted to lead him across the street. Physical exam demonstrates guarding of the extremity with a slightly flexed and pronated arm, elbow swelling, and focal tenderness. A lateral radiograph is shown in Figure A. What is the most appropriate first step in management? Topic

Review Topic

FIGURES: A

1. MRI
2. Aspiration of the elbow joint with blood cultures
3. Closed reduction via supination and flexion
4. Closed reduction via longitudinal traction
5. Placement into long arm splint with no reduction required

PREFERRED RESPONSE ▶

DISCUSSION: The clinical scenario above describes a nursemaids elbow. This injury occurs commonly in children under 5 years of age as a result of a quick pull on an extended and pronated arm and results in subluxation of the annular ligament. Figure A is a lateral radiograph showing normal ossification pattern in a pediatric elbow, without any obvious fracture or dislocation. A lateral radiograph of a nursemaid's elbow will show a normal collinear relationship between capitulum & central axis of the radius. Reduction typically includes elbow flexion and supination while placing a finger on the radial head to feel the snap of the reducing annular ligament.

Krul et al studied manipulative techniques for reduction of nursemaid elbows. Although elbow flexion with forearm supination is the commonly taught technique for reduction, their review mentioned several studies that showed that forearm pronation during reduction may cause less pain and actually be more effective than supination. They concluded further high-quality studies need to be done on this reduction technique.

Illustration A shows the elbow flexion and forearm supination technique used to reduce the subluxated radial head.

Illustrations: A

REFERENCES:

1. Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2012 Jan 18;1 PMID: 22258973 (Link to Abstract)

2. Hart GM. Subluxation of the head of the radius in young children. J Am Med Assoc. 1959 Apr 11;169(15):1734-6. PMID:13640927 (Link to Abstract)

3. Price CT, Flynn JM. Management of fractures. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter's Pediatric Orthopaedics. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1461-1463.

Question Authors:

David Abbasi MD, Eric Shirley MD, John Badylak MD,

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TAG

(OBQ07.69) A 3-year-old boy holds his elbow in a flexed and pronated position and refuses to use it after his mother caught him by the hand as he fell down some stairs. The child will not rotate the forearm and clenches his elbow. Radiographs are negative for fracture. What is the most appropriate course of action? Topic

Review Topic

1. long arm cast
2. MRI of the elbow
3. closed reduction in elbow flexion and supination
4. open reduction and lateral ulnar collateral reconstruction
5. radial head resection

PREFERRED RESPONSE ▶

DISCUSSION: Subluxation of the annular ligament, pulled elbow or nursemaid’s elbow is a common elbow injury in young children. Longitudinal traction on the extended, pronated elbow is the usual mechanism of injury. The history is critical in making the diagnosis, the initial pain usually subsides rapidly and the child does not appear to be in distress, except that he/she is reluctant to use the extremity. Plain radiographs are usually normal although careful review may demonstrate the radiocapitellar line to be lateral to the center of the capitellum in up to 25% of patients. Virtually all annular ligament subluxations are successfully treated by closed reduction. This is usually best done by forearm supination with the elbow flexed. In many patients a snapping sensation can be both heard and palpated when the radial head reduces.

REFERENCES:

1. Stans AA, Heinrich SD: Dislocations of the elbow, in Beaty JH, Kasser JR (eds): Rockwood&Wilkins’ Fractures in Children, ed 6. Philadelphia, PA Lippincott Williams &Wilkins, 2006, pp695-699

Question Authors:

Greg Galano MD, Eric Shirley MD,

Please Rate Educational Value!

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TAG

(OBQ07.143) A 6-year-old boy fell of the monkey bars 5 weeks ago and he has had pain and decreased elbow motion since his fall. His radiographs are shown in figures A and B. What is the most appropriate treatment? Topic

Review Topic

FIGURES: A

1. Bracing and early range of motion
2. Closed reduction of the radial head dislocation with casting in supination and flexion
3. Open reduction internal fixation of medial epicondyle fracture
4. Open reduction internal fixation of lateral condyle fracture
5. Open reduction of radial head dislocation with casting in supination and flexion

PREFERRED RESPONSE ▶

DISCUSSION: The radiographs show a dislocation of the radiocapitellar joint. This is going to require open reduction due to the chronicity of the injury. Treatment options include annular ligament repair, ulnar osteotomy, radial osteotomy or a combination of these procedures. Also, the annular, quadrate, oblique & interosseous ligaments tighten in supination, providing further stability to the proximal radioulnar joint and decreasing the risk of re-dislocation.

It has been published by many authors, including Lincoln et al, that an isolated radial head dislocation does not occur in the pediatric population and that plastic deformation or malunion of the ulna is typically present creating a Monteggia fracture-dislocation variant. The ulnar deformity, if significant, may need to be addressed via osteotomy in the corrective procedure in order to obtain a secure reduction of the radiocapitellar joint. In treating the traumatic radial head dislocation, it is important to consider congenital radial head dislocation and occult monteggia fracture (plastic deformation of the ulna) in the differential diagnosis as this could alter your treatment strategy.

REFERENCES:

1. Lincoln, TL: Isolated traumatic radial head dislocation. J Pediatr Orthop 1994; 14 454-457 PMID:8077426 (Link to Abstract)

2. Rockwood and Wilkins' Fractures in Children. Lippincott Williams & Wilkins; Sixth Edition edition (December 1, 2005).

Question Authors:

Chris Souder MD, Eric Shirley MD, Michael Hughes MD,

Please Rate Educational Value!

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Videos

Nursemaid elbow reduction

Pediatrics - Treatment Consult - Nursemaid's elbow

Shows nursemaid elbow reduction

2/10/2013

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Groups

ABOS II: Radial Head Subluxation (Nursemaid's elbow)

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Hart GM. Subluxation of the head of the radius in young children. J Am Med Assoc. 1959 Apr 11;169(15):1734-6. PMID:13640927 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2012 Jan 18;1 PMID: 22258973 (Link to Abstract)
Lincoln, TL: Isolated traumatic radial head dislocation. J Pediatr Orthop 1994; 14 454-457 PMID:8077426 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Price CT, Flynn JM. Management of fractures. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter's Pediatric Orthopaedics. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1461-1463.
Rockwood and Wilkins' Fractures in Children. Lippincott Williams & Wilkins; Sixth Edition edition (December 1, 2005).

Undefined

Stans AA, Heinrich SD: Dislocations of the elbow, in Beaty JH, Kasser JR (eds): Rockwood&Wilkins’ Fractures in Children, ed 6. Philadelphia, PA Lippincott Williams &Wilkins, 2006, pp695-699

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Nursemaid's elbow

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