An in-depth review of Nursemaid's Elbow.

If you're interested in emergency medicine, pediatrics, or orthopedics you'll definitely want to check this review out.



Radial head subluxation (RHS) is a common injury in children < 4 years old and accounts for up to 20% of UE injuries in children. After 5 years of age, this injury is uncommon because the annular ligament has strengthened.

The typical MOI is a longitudinal traction that leads to subluxation of the radial head and displacement of the annular ligament. It may also result from a fall onto the elbow.



A click may be heard or felt at the time of injury and there may be tenderness over the lateral elbow.

Patients typically refuse to use the affected limb and hold the arm close to their body.

Radiographs are usually not needed unless a fracture is suspected.

Closed reduction is the treatment of choice. Prior to manipulation, it is important to rule out a fracture.

Two reduction techniques may be utilized:
1) Supination-flexion
2) Hyperpronation

In the supination-flexion (SF) technique, the elbow is held at 90° and then the elbow is flexed while supinating the patients' wrist.



In the hyperpronation (HP) technique, the elbow is held at 90° of flexion while firmly pronating the patients' wrist.



"The HP technique has a higher reported first attempt success rate than the SF technique. Studies have also suggested that the HP technique may be less painful than the SF technique." (1)

A 2014 study by Guzel et al reported: "36 of 40 patients (92%) were reduced by hyperpronation on the first attempt, compared with 25 of 38 patients (78%) reduced by SF on the first attempt." (3)

"A successful reduction should result in immediate cessation of pain. Most children will begin to use their arm within 5-10 minutes, and within 30 minutes 90% of children will be asymptomatic." (1)

Conclusion:
RHS is a common injury in children < 4 y.o.
After 5 y.o., RHS is uncommon due to strengthening of the annular ligament.
Closed reduction generally produces great results, and bracing/splinting are usually not recommended

References:
1: https://www.ncbi.nlm.nih.gov/books/NBK430777/
2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999240/
3: https://pubmed.ncbi.nlm.nih.gov/24553032/

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