What is the immediate treatment for a child diagnosed with nursemaid's elbow?

Immediate Treatment for Nursemaid's Elbow

Perform immediate closed reduction using the hyperpronation technique as your first-line maneuver, as it is significantly more effective and less painful than the traditional supination-flexion approach. 1, 2

Reduction Technique Selection

Hyperpronation (First-Line)

• Use hyperpronation as your initial reduction maneuver - it achieves successful reduction on the first attempt in 85% of cases compared to only 53% with supination-flexion. 1
• The technique involves forcibly pronating the forearm while the elbow is held at 90 degrees of flexion. 2
• This single-movement technique is simpler to perform and causes less pain to the child based on validated pain scales. 1, 2
• Meta-analysis of 701 patients demonstrates hyperpronation reduces failure risk by 66% (risk ratio 0.34), with a number needed to treat of only 4 patients. 2

Supination-Flexion (Second-Line)

• Reserve this technique for cases where hyperpronation fails on first attempt. 1
• When hyperpronation fails initially, it still succeeds 50% of the time on second attempt, compared to only 28% for supination-flexion. 1
• The technique involves supinating the forearm while simultaneously flexing the elbow. 3

Clinical Diagnosis

Key Diagnostic Features

• Typical presentation: Child aged 1-4 years with sudden refusal to use the affected arm following a pulling mechanism on an outstretched, pronated forearm. 3, 4
• The child holds the arm in a pronated, slightly flexed position at their side. 3
• No imaging is required for typical presentations - this is a clinical diagnosis that can be confirmed by successful reduction. 3, 4

When to Consider Imaging

• Atypical history (such as fall from height rather than pulling mechanism). 5
• Failed reduction attempts after both techniques. 5
• Concern for alternative diagnoses such as fracture. 4
• MRI can demonstrate annular ligament entrapment in the radiocapitellar joint if reduction is unsuccessful. 5

Post-Reduction Management

Immediate Assessment

• Successful reduction is typically accompanied by a palpable "click" and the child resuming normal arm use within minutes. 3, 4
• The child should be able to use the arm normally, including reaching for objects, within 15-30 minutes of successful reduction. 3

Follow-Up Care

• No immobilization is required after successful reduction of nursemaid's elbow. 3
• Educate parents that recurrence risk exists, particularly in children under 5 years, and to avoid pulling or swinging the child by the arms. 3, 4
• No specific follow-up is needed if the child returns to normal function. 3

Common Pitfalls

• Avoid using supination-flexion as your first technique - this outdated approach has lower success rates and causes more pain. 1, 2
• Do not order radiographs for typical presentations, as they delay treatment and expose the child to unnecessary radiation. 4
• If reduction fails after 2-3 attempts with both techniques, consider alternative diagnoses and obtain imaging to rule out fracture or confirm annular ligament entrapment. 5, 4
• Remember that 65% of foreign body aspiration victims are infants, but this is unrelated to nursemaid's elbow despite similar age demographics. 6