Nursemaid's Elbow Treatment
Perform hyperpronation (forced pronation) as the first-line reduction technique for nursemaid's elbow in a 2-year-old child, as it has superior success rates compared to the traditional supination-flexion method. 1
Immediate Management Algorithm
Initial Assessment
- Confirm typical presentation: Child aged 1-4 years with sudden refusal to use the affected arm after a pulling mechanism (arm held in slight flexion and pronation, with tenderness over the radial head) 2, 3
- No radiographs needed if history is clear and typical (sudden pull on extended arm, classic age range, typical presentation) 3
- Obtain radiographs before reduction if the child is nonambulatory (under 12 months), has atypical mechanism, unclear history, or is older than expected (>4 years), as fractures may masquerade as nursemaid's elbow 2, 4
Reduction Technique: Hyperpronation First
Primary attempt - Hyperpronation technique:
- Grasp the child's elbow with your thumb over the radial head 1
- With your other hand, firmly pronate (rotate palm downward) the forearm while the elbow is flexed at 90 degrees 1
- Success rate: 85% on first attempt, 50% on second attempt 1
If hyperpronation fails - Supination-flexion technique:
- Supinate the forearm (rotate palm upward) while simultaneously flexing the elbow to bring the hand toward the shoulder 1
- Success rate: 53% on first attempt, 28% on second attempt 1
- If supination-flexion fails, return to hyperpronation (100% crossover success rate) 1
Post-Reduction Care
Immediate assessment:
- Child should resume normal arm use within 15-30 minutes after successful reduction 3, 5
- A palpable "click" may be felt during reduction but is not required for success 3
- No immobilization needed after successful reduction 5
Parent education:
- Avoid pulling or lifting the child by the hands or wrists 5
- Recurrence is more common in males and may happen in up to 7% of cases 2
- Return if symptoms persist beyond 30 minutes or recur 5
Critical Pitfalls to Avoid
- Never attempt reduction in nonambulatory infants without radiographs first, as nursemaid's elbow is uncommon in this age group and fractures (including those from abuse) are more likely 4
- Do not persist with supination-flexion if it fails twice—switch to hyperpronation, which has 100% success as a crossover technique 1
- Obtain radiographs if the mechanism is atypical (fall, direct trauma, no clear pulling history) as fractures may present similarly 2
- Consider non-accidental trauma in children with recurrent injuries, inconsistent history, or injuries in nonambulatory infants 4