What is the diagnosis and treatment for nursemaid's elbow (radial head subluxation)?

From the Guidelines

Nursemaid's elbow, also known as radial head subluxation, is a common childhood injury that can be effectively diagnosed and treated with a simple reduction maneuver, and parents should avoid pulling on children's arms to prevent recurrence. The diagnosis of nursemaid's elbow is typically made clinically, based on the presentation of a child who refuses to use their arm, holds it slightly bent, or cries when the arm is moved, after a history of pulling on the child's straightened arm 1.

Key Points to Consider

• The reduction maneuver involves flexing the elbow while rotating the forearm, which is usually quick and provides immediate relief, with most children regaining normal arm use within minutes 1.
• No medication is typically required, though acetaminophen or ibuprofen may be given for any residual discomfort.
• Parents should avoid pulling on children's arms and instead lift children under the armpits to prevent recurrence.
• After reduction, no immobilization is needed, and recurrence is possible but becomes less likely as the child grows and ligaments strengthen.
• If a child refuses to use their arm, holds it slightly bent, or cries when the arm is moved, seek medical attention promptly as these are classic signs of nursemaid's elbow.

Imaging Studies

While imaging studies such as radiography, CT, or MRI may be used to evaluate acute elbow or forearm pain, they are not typically necessary for the diagnosis of nursemaid's elbow, unless there is suspicion of a more serious injury, such as a fracture or dislocation 1. In such cases, the American College of Radiology recommends radiography as the initial imaging study, followed by CT or MRI if necessary 1. However, for nursemaid's elbow, the focus should be on prompt reduction and prevention of recurrence, rather than on imaging studies.

From the Research

Diagnosis of Nursemaid's Elbow

• Nursemaid's elbow, also known as pulled elbow or subluxation of the radial head, is a common injury in young children, typically resulting from a sudden pull on the arm, which pulls the radius through the annular ligament, resulting in subluxation of the radial head 2, 3, 4, 5, 6.
• The child experiences sudden acute pain and loss of function in the affected arm 2, 3, 4, 5, 6.

Treatment of Nursemaid's Elbow

• The treatment for nursemaid's elbow usually involves manual reduction of the subluxed radial head 2, 3, 4, 5, 6.
• Various manoeuvres can be applied, including supination of the forearm, often combined with flexion, and (hyper-)pronation 2, 3, 4.
• There is low-quality evidence that hyperpronation may be more effective than supination-flexion, with a lower failure rate at the first attempt 2.
• Pronation may also be less painful than supination, although the evidence is limited and of low quality 3, 4.
• The choice of treatment method may depend on the individual case and the preference of the healthcare provider, with some studies suggesting that hyperpronation may be more effective for the second attempt after initial failure 2.

Methods of Reduction

• Supination-flexion and hyperpronation are two common methods used for reduction of the annular ligament in nursemaid's elbow 2, 3, 4, 5.
• Supination-extension is another method that has been compared to supination-flexion, although the evidence is limited and of very low quality 2.
• The effectiveness and painfulness of these methods may vary, and further research is needed to determine the most effective and comfortable method for reducing nursemaid's elbow 2, 3, 4.