What is the immediate treatment for nursemaid elbow in a child?

Immediate Treatment for Nursemaid's Elbow in a Child

The immediate treatment for nursemaid's elbow is reduction using the hyperpronation maneuver, which has a higher success rate than the supination-flexion technique and can be safely performed in an office or emergency department setting without sedation. 1

Understanding Nursemaid's Elbow

Nursemaid's elbow, also known as radial head subluxation, is a common pediatric orthopedic injury that typically occurs in children 1-4 years of age. It results from:

• Axial traction or sudden pull on an extended pronated arm
• Activities such as swinging a child by the hands
• Pulling on the child's arm while the forearm is pronated

The injury involves subluxation of the radial head where the annular ligament becomes entrapped in the radiocapitellar joint.

Clinical Presentation

The classic presentation includes:

• Child refusing to use the affected arm
• Arm held close to the body in slight flexion and pronation
• Minimal pain when the arm is not moved
• No obvious swelling or deformity
• History of pulling or lifting the child by the arm

Reduction Techniques

Primary Technique: Hyperpronation Maneuver

1. Hold the child's elbow at 90° flexion
2. Firmly pronate the wrist with a quick movement
3. A "click" may be felt as the radial head reduces
4. Success rate of approximately 80% on first attempt

Alternative Technique: Supination-Flexion Maneuver

1. Hold the elbow at 90° flexion with one hand
2. Rapidly supinate and flex the elbow with the other hand
3. This technique has been shown to be less effective than hyperpronation

Management Algorithm

1. Identify clinical presentation consistent with nursemaid's elbow
2. Attempt hyperpronation maneuver first
3. If unsuccessful, attempt a second time
4. If still unsuccessful after two attempts:
   • Splint the arm
   • Refer for further evaluation to rule out fracture or other pathology
   • Consider imaging studies

Important Considerations

• No sedation is required for the reduction procedure
• Reduction can be safely performed in an office setting
• Success is indicated by the child's willingness to use the arm again within minutes
• In atypical presentations or failed reduction, imaging may be necessary to rule out other conditions 2
• In rare cases, MRI may be needed to confirm the diagnosis and successful reduction in atypical cases 2

Prevention Education

After successful reduction, provide education to caregivers about:

• Avoiding activities that involve pulling on a child's arm
• Not swinging children by their hands or arms
• Proper ways to lift a child (under the axilla rather than by the hands)
• The possibility of recurrence (common in this condition)

Follow-up

• Most children return to normal arm use within 5-10 minutes after successful reduction
• No specific follow-up is typically needed after successful reduction
• If symptoms persist or recur frequently, further evaluation may be warranted

Nursemaid's elbow is a preventable injury that can be easily diagnosed and treated in the primary care or emergency setting, with excellent outcomes when properly managed.