Treatment of Nursemaid's Elbow (Radial Head Subluxation)
The pronation method is the preferred reduction technique for nursemaid's elbow, as it is more effective and less painful than the traditional supination method. 1
Clinical Recognition
Nursemaid's elbow is a radial head subluxation that occurs when the radius is pulled through the annular ligament, typically in children 1-4 years of age following a sudden pull on the arm by an adult or taller person. 1, 2 The child presents with:
- Sudden acute pain and refusal to use the affected arm 1, 3
- The arm held in a pronated position at the side 2
- This is primarily a clinical diagnosis 2
Reduction Technique: Pronation Method (Preferred)
The pronation method should be your first-line approach, with evidence showing:
- Significantly lower failure rates compared to supination (21/177 failures with pronation versus 47/181 with supination; risk ratio 0.45) 1
- Less painful for the child during the procedure 1
- Can be successfully performed even by trained non-medical caretakers via telephone instruction in recurrent cases 4
Supination Method (Alternative)
While traditionally recommended in textbooks, the supination method is less effective and more painful than pronation. 1 It may be attempted if pronation fails on the first attempt. 1
Imaging Considerations
- Radiographs are not routinely necessary for typical presentations 2
- Consider imaging if there is concern for fracture, particularly with atypical mechanism or presentation 2
- In adults with similar presentations (rare), imaging should be obtained as radial head dislocation is usually associated with fractures or elbow dislocation 5
Success Indicators and Follow-up
- Successful reduction is typically followed by immediate return of arm function 2, 3
- If reduction fails after 1-2 attempts with both techniques, obtain radiographs to rule out fracture 2
- Parent education should include mechanism of injury to prevent recurrence 3
Important Clinical Pitfall
While nursemaid's elbow is predominantly a pediatric injury (children under 7 years), it can rarely occur in adults. 5 In adult presentations, maintain higher suspicion for associated fractures or more complex injuries, as isolated radial head subluxation without fracture is uncommon in this population. 5