What is the treatment for nurse's elbow?

Treatment of Nurse's Elbow (Radial Head Subluxation)

Hyperpronation is the most effective first-line reduction technique for nurse's elbow, with a 91% success rate compared to 74% for supination-flexion, reducing failures by 174 per 1000 children treated. 1

What is Nurse's Elbow?

Nurse's elbow (nursemaid's elbow or radial head subluxation) occurs when the radial head slips through the annular ligament, typically from sudden traction on an extended, pronated arm in children aged 1-4 years. 1, 2 The child presents with acute pain, refusal to use the affected arm, and the limb held in a pronated, slightly flexed position. 2, 3

Diagnosis

• Clinical diagnosis is based on mechanism of injury (pulling on extended arm) and characteristic presentation of arm held protectively at the side with refusal to use it. 2
• Imaging is NOT routinely needed for typical presentations with clear mechanism and no trauma. 1
• Plain radiographs should be obtained if the history is atypical, there was significant trauma, reduction attempts fail, or you suspect fracture. 4, 3
• MRI may be considered only in unusual cases where reduction fails and entrapment of the annular ligament is suspected. 4

Treatment Algorithm

First Reduction Attempt

Perform hyperpronation as the primary technique: 1

• Grasp the child's elbow with your thumb over the radial head
• With your other hand, firmly hyperpronate the forearm (palm down to palm up and beyond)
• You may feel a click as the radial head reduces
• Success rate: 91% on first attempt 1

Alternative if hyperpronation fails - supination-flexion: 1

• Supinate the forearm fully (palm up)
• Then flex the elbow maximally while maintaining supination
• Success rate: 74% on first attempt 1

The number needed to treat is 6, meaning for every 6 children treated with hyperpronation instead of supination-flexion, one additional failure is prevented. 1

If First Attempt Fails

• Repeat the hyperpronation maneuver - this is more effective than repeating supination-flexion for second attempts. 1
• If still unsuccessful after 2-3 attempts, obtain radiographs to rule out fracture or confirm diagnosis. 4, 3

After Successful Reduction

• No immobilization is typically needed - the child should resume normal arm use immediately after successful reduction. 2
• Confirm success by observing the child spontaneously use the arm within 10-15 minutes (reaching for toys, bringing hand to mouth). 2
• Parent education should include avoiding pulling on the child's arm and recognizing recurrence risk (approximately 20-40% will have repeat episodes). 2

Atypical Cases Requiring Specialist Referral

• Reduction attempts fail after 2-3 tries 4
• Radiographs show fracture or other pathology 3
• Presentation is atypical (significant trauma, delayed presentation >24 hours, neurological symptoms) 4
• In these cases, consider immobilization with backslab in supinated position and orthopedic follow-up. 3

Common Pitfalls

• Using supination-flexion as first-line when hyperpronation has superior success rates. 1
• Obtaining unnecessary radiographs in typical presentations, which delays treatment and exposes children to radiation. 1, 2
• Failing to educate parents about prevention and recurrence risk. 2
• Not confirming successful reduction by observing spontaneous arm use before discharge. 2