Updated: 4/29/2019

Nursemaid's Elbow

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Review Topic
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Questions
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Evidence
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https://upload.orthobullets.com/topic/4012/images/nursemaid_ultrasound.jpg
https://upload.orthobullets.com/topic/4012/images/nursemaid elbow.jpg
https://upload.orthobullets.com/topic/4012/images/nursemaid hyperpronation.jpg
https://upload.orthobullets.com/topic/4012/images/nursemaid flexion_supination.jpg
Introduction
  • Overview
    • 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
      • 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
  • 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
  • Prognosis
    • excellent when reduced in a timely manner
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 Diagnosis
  • 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
 

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Questions (2)

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(OBQ11.97) A 3-year-old male has a refusal to move 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 the elbow held in flexed and pronated position. A lateral radiograph is shown in Figure A. What is the most appropriate first step in management? Review Topic

QID: 3520
FIGURES:
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1

MRI

1%

(14/1800)

2

Aspiration of the elbow joint with blood cultures

0%

(2/1800)

3

Closed reduction via supination and flexion

93%

(1677/1800)

4

Closed reduction via longitudinal traction

2%

(30/1800)

5

Placement into long arm splint with no reduction required

4%

(66/1800)

L 1

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SUBMIT RESPONSE 3

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(OBQ07.69) A 2-year-old is brought to the emergency room with reports of acute elbow pain and limited use of the left upper extremity. The patient is neurovascularly intact and is afebrile. Examination reveals that the elbow is in slight flexion and the forearm pronated but further examination is limited secondary to pain. AP and lateral radiographs are shown in Figures A and B. What is the next best step in management? Review Topic

QID: 730
FIGURES:
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1

Observation

2%

(51/2419)

2

MRI

2%

(49/2419)

3

Supination and flexion reduction maneuver

88%

(2118/2419)

4

Supination reduction maneuver with long arm casting

6%

(139/2419)

5

Closed reduction and percutaneous pinning

2%

(54/2419)

L 1

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SUBMIT RESPONSE 3
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