Nursemaid's Elbow: Natural History Without Reduction
Nursemaid's elbow will typically self-reduce spontaneously if left untreated, though this may take hours to days and subjects the child to unnecessary pain and functional limitation during that period. While spontaneous reduction can occur, immediate manual reduction is the standard of care because it provides instant relief and restoration of function 1, 2, 3.
Clinical Course Without Intervention
Spontaneous Resolution
- The subluxed radial head can spontaneously reduce on its own through natural arm movements and positioning changes 4, 1.
- The timeframe for spontaneous reduction is unpredictable and variable, ranging from several hours to potentially days 3.
- During this waiting period, the child experiences continued pain and refuses to use the affected extremity, significantly impacting quality of life 1, 2.
Why Immediate Reduction is Preferred
- Manual reduction techniques (hyperpronation or supination-flexion) provide immediate pain relief and functional restoration in the majority of cases 2.
- Hyperpronation technique demonstrates 85% success on first attempt, compared to 53% for supination-flexion 2.
- Reduction is a simple, one-movement technique that can be performed without sedation in most cases 1, 2.
- Successful reduction is typically confirmed by immediate return of arm function and cessation of pain 2, 3.
Clinical Pitfalls and Atypical Presentations
When Reduction Fails
- If typical reduction maneuvers are unsuccessful after multiple attempts, consider atypical presentations or alternative diagnoses 4.
- Imaging (particularly MRI) may be warranted when the history is atypical or reduction attempts fail, as the annular ligament may be entrapped in the radiocapitellar joint 4.
- Standard radiographs are often normal in nursemaid's elbow, but may be useful to exclude fractures when the mechanism or presentation is atypical 3.
Risk of Delayed Treatment
- Prolonged subluxation without reduction subjects the child to unnecessary pain and functional impairment 1, 2.
- While no evidence suggests permanent damage from delayed reduction, the morbidity from pain and loss of function during the waiting period is clinically significant 1, 3.
- Parents may seek multiple medical evaluations if the condition is not promptly recognized and treated, increasing healthcare utilization 1.
Recommended Approach
Immediate manual reduction should be attempted as first-line treatment for suspected nursemaid's elbow 2, 3:
- Use hyperpronation as the initial technique (85% first-attempt success rate) 2.
- If hyperpronation fails, attempt supination-flexion as a crossover technique 2.
- Successful reduction is confirmed by immediate return of normal arm use and resolution of pain 1, 2.
- If reduction attempts fail after 2-3 maneuvers, consider imaging to evaluate for atypical presentations or alternative diagnoses 4, 3.