Nursemaid's Elbow (Radial Head Subluxation): Immediate Reduction
Perform immediate closed reduction of the radial head subluxation without obtaining radiographs first, as this is the classic presentation of nursemaid's elbow in a 2-year-old child.
Clinical Presentation Confirms Radial Head Subluxation
The clinical scenario is pathognomonic for radial head subluxation (nursemaid's elbow):
- Age: 2 years old is the peak age for this injury (mean age 27 months) 1
- Mechanism: Swinging the arm in circles ("playing airplane") represents the classic traction mechanism 1
- Physical findings: Arm held dangling at the side with refusal to move it and crying when the elbow is touched 1
- Absence of red flags: No swelling, no deformity, no point tenderness 1
Radial head subluxation is the most frequent diagnosis (63%) in children under 6 years presenting with upper extremity immobility 1. Multivariate analysis shows that decreased arm movement, absence of swelling, and a pull mechanism strongly correlate with radial head subluxation rather than fracture 1.
Immediate Management: Reduction Technique
Proceed directly to closed reduction without imaging, using one of two techniques:
- Supination-flexion method: Supinate the forearm while flexing the elbow to 90 degrees 1
- Hyperpronation method: Forcefully pronate the forearm (some evidence suggests higher success rates with this technique)
A palpable "click" at the radial head often indicates successful reduction 1. The child typically resumes normal arm use within 15-30 minutes after successful reduction 1.
When to Obtain Radiographs
Skip radiographs initially unless any of these features are present 1, 2:
- Point tenderness over a specific bone 1
- Visible swelling or deformity 1
- Age less than 6 months (consider non-traumatic causes like infection or neurologic impairment) 1
- Unclear or high-energy mechanism of injury 2
- Failed reduction attempt 1
If reduction fails or the child doesn't improve within 30 minutes, obtain radiographs of the elbow and forearm to rule out occult fracture 1, 2.
Point-of-Care Ultrasound Option
If available and you have expertise, point-of-care ultrasound can screen for fracture before attempting reduction in equivocal cases 2. This increases safety by identifying occult fractures that would contraindicate blind reduction attempts 2. However, in this classic presentation, ultrasound is unnecessary and would delay definitive treatment.
Post-Reduction Care
- Observe for 15-30 minutes to ensure return of normal arm function 1
- No immobilization needed if the child resumes normal activity 1
- Discharge with reassurance: All children with radial head subluxation recover completely by 1 week 1
- Recurrence counseling: Advise parents to avoid pulling or swinging the child by the arms, as recurrence rates can be significant
Critical Pitfall to Avoid
Do not obtain radiographs first in classic presentations, as this delays treatment, exposes the child to unnecessary radiation, and increases healthcare costs 1. The combination of appropriate age, classic mechanism, and absence of swelling/point tenderness makes fracture highly unlikely (sensitivity of clinical findings for RHS vs. fracture is statistically significant, P < .05) 1.