Nursemaid Elbow

Nursemaid Elbow

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Nursemaid elbow, also known as “radial head subluxation” or simply “pulled elbow”, is the most common upper-limb injury in children under the age of 6. [1, 33] It is typically an easily treatable condition. Correct diagnosis is the primary challenge to the physician.

The etiology is movement of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn. As children age, the annular ligament strengthens. In children over the age of 5, subluxation of the radial head is prevented by a thicker and stronger attachment between the annular ligament and the periosteum of the radial neck. [2]    As a result, nursemaid’s elbow occurs less often.

A Nursemaid’s Elbow (NE) is a low-energy trauma often occurring from brisk axial traction of the forearm, often by an adult who holds the child’s hand as the child pulls away. Other causes of injury include falls, wrestling, and abuse. [3]

The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm. The common belief that nursemaid elbow is due to children having a radial head smaller than the radial neck is incorrect.

Published case series report a slight predominance in females. [4, 5]

Published case series report a slight left arm predominance in both males and females. [4, 5]

A study by Wong et al that reviewed 246 pediatric ED visits for radial head subluxation reported that recurrence was more likely in male patients. [6]

Nursemaid elbow most commonly occurs in children aged 1-4 years. However, it has been reported in patients as young as 4 months and as old as 31 years. [7]

A study that examined the epidemiological description of radial head subluxation found that the average age of children presenting with nursemaid’s elbow was 28.6 months. [5]

The prognosis is excellent. Parents can be reassured that no permanent injury results from this condition.

For those who have had one occurrence, the chance of recurrence is approximately 20-25%. [4, 8]  Those 24 months and younger may have the greatest risk of recurrence. [8]

Most parents appreciate knowing that reoccurrence can occur in 1/5-1/4 of patients.

Schutzman SA, Teach S. Upper-extremity impairment in young children. Ann Emerg Med. 1995 Oct. 26 (4):474-9. [Medline].

Salter RB, Zaltz C. Anatomic investigations of the mechanism of injury and pathologic anatomy of “pulled elbow” in young children. Clin Orthop Relat Res. 1971. 77:134-43. [Medline].

Eismann EA, Cosco ED, Wall EJ. Absence of Radiographic Abnormalities in Nursemaid’s Elbow. J Pediatr Orthop. 2014. 34(4):426-31.

Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med. 1990 Sep. 19(9):1019-23. [Medline].

Vitello S, Dvorkin R, Sattler S, Levy D, Ung L. Epidemiology of Nursemaid’s Elbow. West J Emerg Med. 2014 Jul. 15 (4):554-7. [Medline].

Wong K, Troncoso AB, Calello DP, Salo D, Fiesseler F. Radial Head Subluxation: Factors Associated with Its Recurrence and Radiographic Evaluation in a Tertiary Pediatric Emergency Department. J Emerg Med. 2016 Dec. 51 (6):621-627. [Medline].

Pearson BV, Kuhns DW. Nursemaid’s elbow in a 31-year-old female. Am J Emerg Med. 2007 Feb. 25(2):222-3. [Medline].

Teach SJ, Schutzman SA. Prospective study of recurrent radial head subluxation. Arch Pediatr Adolesc Med. 1996 Feb. 150(2):164-6. [Medline].

Michaels MG. A case of bilateral nursemaid’s elbow. Pediatr Emerg Care. 1989 Dec. 5(4):226-7. [Medline].

Diab HS, Hamed MMS, Allam Y. Obscure pathology of pulled elbow: dynamic high-resolution ultrasound-assisted classification. ournal of Children’s Orthopaedics. 2010. 4(6):539-543.

Kosuwon W, Mahaisavariya B, Saengnipanthkul S, et al. Ultrasonography of pulled elbow. J Bone Joint Surg Br. May 1993. 75(3):421-2.

Dohi, D. Confirmed specific ultrasonographic findings of pulled elbow. J Pediatr Orthop. 2013 Dec. 33(8):829-31.

Sohn Y, Lee Y, Oh Y, Lee W. Sonographic finding of a pulled elbow: the “hook sign”. Pediatr Emerg Care. 2014 Dec. 30 (12):919-21. [Medline].

Rabiner JE, Khine H, Avner JR, Tsung JW. Ultrasound findings of the elbow posterior fat pad in children with radial head subluxation. Pediatr Emerg Care. 2015 May. 31 (5):327-30. [Medline].

Rabiner JE, Khine H, et al. Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children. Ann Emerg Med. Jan 2013. 61:9-17.

Shabet S, Folman Y, Mann G, Kots Y, Fredman B, Banian M, et al. The role of sonography in detecting radial head subluxation in a child. Case Report. J Clinical Ultrasound. May 2005. 33(4):187-9. [Medline].

Pai DR, Thapa M. Musculoskeletal ultrasound of the upper extremity in children. Pediatr Radiol. 2013 Mar. 43 Suppl 1:S48-54. [Medline].

Güngör F, Kılıç T. Point-of-Care Ultrasonography to Assist in the Diagnosis and Management of Subluxation of the Radial Head in Pediatric Patients: A Case Series. J Emerg Med. 2017 May. 52 (5):702-706. [Medline].

Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child. 1985 Dec. 139(12):1194-7. [Medline].

Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 1998 Jul. 102(1):e10. [Medline].

McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med. 1999 Jul. 6(7):715-8. [Medline].

Green DA, Linares MY, Garcia Peña BM, Greenberg B, Baker RL. Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. Pediatr Emerg Care. 2006 Apr. 22(4):235-8. [Medline].

Bek D, Yildiz C, Köse O, Sehirlioglu A, Basbozkurt M. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial. Eur J Emerg Med. 2009 Jun. 16(3):135-8. [Medline].

27. Gunaydin YK, Katirci Y, Duymaz H, Vural K, Halhalli HC, Akcil M, et al. Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid’s elbow cases. Am J Emerg Med. 2013. 31(7):1078-81.

García-Mata S, Hidalgo-Ovejero A. Efficacy of reduction maneuvers for “pulled elbow” in children: a prospective study of 115 cases. J Pediatr Orthop. 2014 Jun. 34 (4):432-6. [Medline].

Guzel M, Salt O, Demir MT, Akdemir HU, Durukan P, Yalcin A. Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation. Niger J Clin Pract. 2014 Mar-Apr. 17 (2):201-4. [Medline].

Dr. Vader. Nursemaid Elbow manipulation. Available at http://www.youtube.com/watch?v=rxrrkMcgx2Y. Accessed: January 31, 2014.

Mellick L. Nursemaid Elbow Reduction. Available at http://www.youtube.com/watch?v=-0ROu4hCXwQ. Accessed: January 31, 2014.

Aylor MI, Anderson JM, Vanderford P, et al. Videos in clinical medicine. Reduction of pulled elbow. N Engl J Med. 20 Nov 2014. 371(21):e32:[Full Text].

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. 1-18.

Stone CA. Subluxation of the head of the radius. JAMA. 1916. 67:28-9.

Van Arsdale WH. On subluxation of the head of the radius in children with a resume of one hundred consecutive cases. Ann Surg. 1889. 9:401-23.

Nardi NM, Schaefer TJ. Nursemaid Elbow. StatPearls [Internet]. 2018 Jan. [Medline]. [Full Text].

Bertucci N, Cowling K. Is Hyperpronation More Effective Than Supination for Reduction of a Radial Head Subluxation?. Ann Emerg Med. 2018 Nov. 72 (5):586-587. [Medline].

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Devin N Boss, DO Attending Physician, Department of Emergency Medicine, St John’s Clinic

Devin N Boss, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mark Panetta, MD Resident Physician, Department of Emergency Medicine, Mercy St Vincent Medical Center

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Grace M Young, MD Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children’s Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Garry Wilkes, MBBS, FACEM Director of Clinical Training (Simulation), Fiona Stanley Hospital; Clinical Associate Professor, University of Western Australia; Adjunct Associate Professor, Edith Cowan University, Western Australia

Disclosure: Nothing to disclose.

Nursemaid Elbow

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