14-40: Nursemaid’s Elbow (Radial Head Subluxation)

Clinical Summary

Nursemaid’s elbow is a condition that occurs commonly in children younger than 6 years of age who are usually picked up or pulled by the extended, pronated arm. The peak incidence is 2 to 3 years of age. These children present unwilling to supinate or pronate the hand on the affected side. Generally they hold the affected arm close to their side in a passive pronation with partial flexion at the elbow. Radiographic studies should be considered only in patients with an unusual mechanism of injury, with significant bony tenderness, or who do not become rapidly asymptomatic after the reduction maneuver. The differential diagnosis includes radial head fracture or complete dislocation, posterior elbow dislocation, condylar and supracondylar fractures of the distal humerus, or buckle fracture of the radius or ulna.

Management and Disposition

Carefully palpate all points of the affected arm for tenderness. There should be minimal to no pain with palpation. Orthopedic consultation is generally not indicated unless an underlying fracture is diagnosed. Reduction is usually achieved by one of two maneuvers:

1. Hyperpronation. While holding the elbow in extension, hyperpronation of the forearm is maintained until reduction is achieved.

2. Flexion/supination. Beginning with the elbow flexed at 90 degrees, the wrist of the affected arm is grasped with one hand, while the other stabilizes the elbow. The forearm is then gently supinated while the arm is flexed until the palm approaches the anterior shoulder.

In either maneuver, a palpable click over the radial head is evident upon successful reduction. Studies have indicated that hyperpronation is more likely to be successful when used as the initial reduction maneuver. The patient usually begins using the arm normally within minutes. When the injury has been present for several hours, reduction may be difficult, and it may take several hours to recover full function of the elbow.

Pearls

1. Radiographs of radial head subluxation typically appear normal.

2. Immobilization after reduction is not necessary.

3. If the patient remains symptomatic after reduction attempts, obtain x-rays to assess for fractures.

4. Up to one-third of children will have recurrence, but rarely beyond age 4 to 5 years.