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Updated: Aug 21 2022

Nursemaid's Elbow

Images elbow.jpg hyperpronation.jpg flexion_supination.jpg
  • summary
    • Nursemaid's Elbow is a common injury of early childhood that results in subluxation of the annular ligament due to a sudden longitudinal traction applied to the hand.
    • Diagnosis can be made clinically with a child that holds the elbow in slight flexion with pain and tenderness localized to the lateral aspect of the elbow.
    • Treatment is usually closed reduction with either a supination or a hyperpronation technique.
  • Epidemiology
    • Incidence
      • common
    • Demographics
      • most common in children from 1 to 4 years of age
        • average age is 28 months
        • rare after 5 years of age
      • slightly more common in females
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • sudden, longitudinal traction applied to the hand with the elbow extended and forearm pronated
        • may also be caused by a fall
      • pathoanatomy
        • annular ligament becomes interposed between radial head and capitellum
        • in children 5 years of age or older, subluxation is prevented by a thicker and stronger distal attachment of the annular ligament
  • Presentation
    • History
      • a click may be heard or felt by the person pulling the child's arm
    • Symptoms
      • child refuses to use the affected limb
      • holds the elbow in slight flexion and the forearm pronated
    • Physical Exam
      • pain and tenderness localized to the lateral aspect of the elbow
      • range of motion
        • full flexion and extension
        • pain with supination
  • Imaging
    • Radiographs
      • not required in the setting of the classic presentation of
        • history of traction injury
        • child five years or younger
        • consistent clinical exam
      • when obtained, elbow radiographs are normal
        • 25% will show radiocapitellar line slightly lateral to center of capitellum
    • Ultrasound
      • indications
        • helpful for confirming the diagnosis when necessary
        • when the mechanism of injury is not evident
        • when physical examination is inconclusive
      • benefits
        • no radiation to the patient
        • can visualize soft tissues
      • findings
        • increase echo-negative area between capitellum and radial head
      • sensitivity 64.9% and specificity 100%
  • Differential
    • Nursemaid elbow is a diagnosis of exclusion
    • Differential diagnosis of a painful elbow with limited supination
      • traumatic causes
        • supracondylar fracture, olecranon fracture, radial neck fracture, lateral condyle fracture
        • contusion
      • infection
        • septic arthritis
      • congenital
        • radial head dislocation
        • forearm synostosis
  • Treatment
    • Nonoperative
      • closed reduction of annular ligament subluxation
        • indications
          • for majority of cases
            • must be certain no fracture is present prior to any manipulation
    • Operative
      • open reduction rarely required
        • indications
          • for chronic, symptomatic subluxations that cannot be reduced
  • Techniques
    • Closed reduction of annular ligament subluxation
      • supination technique
        • while holding the arm supinated the elbow is then maximally flexed
        • the physician’s thumb applies pressure over the radial head and a palpable click is often heard with reduction of the radial head
      • hyperpronation technique
        • involves hyperpronation of the forearm while in the flexed position
      • followup
        • child should begin to use the arm within minutes after reduction
        • immobilization is unnecessary after first episode
  • Complications
    • Recurrence
      • may occur, especially if the child is younger than 3 years
      • initially treat with cast application in flexion and neutral or supination
  • Prognosis
    • Excellent when reduced in a timely manner
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