In a child under 5 years old with classic nursemaid elbow presentation and a normal neurovascular exam, is it acceptable to perform reduction without obtaining a prior X‑ray?

Nursemaid Elbow Reduction Without Prior X-ray

Yes, it is acceptable to perform nursemaid elbow reduction before obtaining an x-ray in children under 5 years old with a classic presentation and normal neurovascular exam, provided there is a clear history of sudden traction on an extended arm by an adult. However, radiographs should be obtained first if the history is atypical, unclear, or if the child is non-ambulatory.

When X-ray is NOT Required Before Reduction

Reduction without prior imaging is appropriate only when ALL of the following criteria are met:

• Classic mechanism of injury: Abrupt traction by an adult attending person on an outstretched arm is positively reported 1
• Age 1-4 years: This is the typical age range for nursemaid elbow 2
• Ambulatory child: Non-ambulatory infants should always receive x-rays first 3
• Minimal or no soft tissue swelling: Moderate or major swelling is uncommon in radial head subluxation and suggests fracture 1
• Child refuses to use the affected arm: This is the typical presentation 2
• Normal neurovascular examination: No signs of vascular or nerve injury

When X-ray is MANDATORY Before Reduction Attempt

Obtain radiographs before any reduction attempt if ANY of the following are present:

• Non-ambulatory infant: Nursemaid elbow is uncommon in this age group, and fractures (including those indicating abuse) must be excluded 3
• Atypical or unclear history: When the mechanism of injury is unknown or doesn't fit the classic traction pattern 1
• Fall reported as mechanism: In one series, 54.5% of children with fractures misdiagnosed as nursemaid elbow had a fall reported rather than traction 1
• Moderate or major soft tissue swelling: Present in 36.4% of missed fractures, this is uncommon in true radial head subluxation 1
• Point tenderness over bone: Suggests fracture rather than subluxation
• Any concern for non-accidental trauma: Forearm fractures in non-ambulatory infants may be indicators of abuse 3

Common Pitfalls and Missed Diagnoses

The most frequently missed fracture misdiagnosed as nursemaid elbow is supracondylar humerus fracture, which accounted for 36% of cases in one series 1. Other missed injuries include:

• Supracondylar humerus fractures (most common) 1
• Forearm fractures in infants 3
• Other elbow fractures 1

Critical warning signs that distinguish fracture from nursemaid elbow:

• History of fall rather than traction (present in >50% of missed fractures) 1
• Moderate to major soft tissue swelling (present in 36% of missed fractures) 1
• Mechanism of injury unknown or unreported (present in 36% of missed fractures) 1
• Non-ambulatory status in infants 3

Clinical Algorithm for Decision-Making

Step 1: Verify the child is 1-4 years old and ambulatory 3, 2

Step 2: Confirm classic history of sudden traction by adult on extended arm 1

Step 3: Assess for soft tissue swelling - if moderate or major, obtain x-ray first 1

Step 4: If all criteria met, proceed with reduction attempt 1

Step 5: If reduction unsuccessful or symptoms persist, obtain radiographs to rule out fracture 1

Evidence Supporting Clinical Diagnosis

High-frequency ultrasonography can detect the "partial eclipse sign" in nursemaid elbow, which disappears after successful reduction 4. However, this is not routinely available in most emergency settings and clinical diagnosis remains standard 2.

The diagnosis of nursemaid elbow is primarily clinical, and imaging is not routinely required when the presentation is classic 2. However, the threshold for obtaining radiographs should be low when any atypical features are present 1, 3.