Nursemaid’s elbow: Its diagnostic clues and preferred means of reduction

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Original Research

Nursemaid’s elbow: Its diagnostic clues and preferred means of reduction

J Fam Pract. 2010 January;59(1):E5-E7

By

Marjolein Krul, MD

Johannes C. Van Der Wouden, MD

Francois G. Schellevis, MD

This systematic review revealed that correcting the injury with pronation is more successful and less painful than supination.

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References

1. Salter RB, Zaltz C. Anatomic investigations of the mechanism of injury and pathologic anatomy of “nursemaid’s elbow” in young children. Clin Orthop Relat Res. 1971;77:134-143.

2. Hagroo GA, Zaki HM, Choudhary MT, et al. Nursemaid’s elbow-not the effect of hypermobility of joints. Injury. 1995;26:687-690.

3. Griffin ME. Subluxation of the head of the radius in young children. Pediatrics. 1955;15:103-106.

4. Illingworth CM. Pulled elbow: a study of 100 patients. Br Med J. 1975;2:672-674.

5. Magill HK, Aitken AP. Nursemaid’s elbow. Surg Gynecol Obstet. 1954;98:753-756.

6. Bobrow RS. Childhood radial head subluxation. Physician unfamiliarity with “nursemaid’s” or “pulled” elbow. NY State J Med. 1977;77:908-909.

7. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomised clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1-12.

8. Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child. 1985;139:1194-1197.

9. Teach SJ, Schutzman SA. Prospective study of recurrent radial head subluxation. Arch Pediatr Adolesc Med. 1996;150:164-166.

10. Lyver MB. Radial head subluxation. J Emerg Med. 1991;9:154-156.

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PRACTICE RECOMMENDATIONS

• Nursemaid’s elbow typically occurs with a sudden pull on a child’s arm. Reserve radiography for uncertain cases in which you need to exclude more severe injuries. B

• Consider reducing nursemaid’s elbow by rapid pronation of the forearm, which has been shown to be less painful and more effective than supination. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Nursemaid’s elbow—sudden subluxation of the radial head—usually results from forcible traction to a child’s pronated hand or wrist, with the elbow extended.¹ Ironically, this can occur when a parent tries to maneuver a child away from perceived danger, and the child experiences pain and acute loss of function of the affected limb.²

Nursemaid’s elbow reportedly occurs frequently among children,^3,4 and thus we would expect to encounter it often in primary care. However, this condition receives little attention in medical training or in the literature, and many physicians do not recognize it.^4-6

In this article we describe the epidemiology, underlying pathology, diagnosis, and treatment of nursemaid’s elbow, based on a systematic review of the current literature.

Methods

Literature search
Using PubMed and Embase, we conducted a literature search for articles published in Dutch, English, German, or French from 1966 through July 2007 on the topic of nursemaid’s elbow in children. We used as search terms all known synonyms for nursemaid’s elbow—eg, radial head subluxation, partial epiphyseal separation of the radial head, pulled elbow, babysitter’s elbow, curbstone fracture, etc. Publications cited in our initial search were also checked for relevance. Articles were reviewed and judged independently by 2 authors (M.K. and J.C.v.d.W.).

Articles we selected focused on proximal radial subluxation. We excluded articles on distal radial subluxation and luxation of the radius.

The 2 reviewers assessed the quality of articles on treatment using the validated Jadad score,⁷ wherein a maximum of 5 points may be awarded:

1 point if the study is described as randomized:
1 point if the study is described as double-blind:
1 point for a description of withdrawals or dropouts.

No cutoff limit for Jadad scores was planned as a criterion for exclusion. As it is not possible to treat nursemaid’s elbow in a double-blind fashion, 3 was the highest possible score in our study.

Results

Our literature search produced 368 potentially relevant papers; of these, 60 met our inclusion criteria. The reference lists of selected studies and reviews yielded an additional 25 acceptable papers, each covering various aspects of the topic (epidemiology, 19; pathology, 10; diagnosis, 10; treatment, 9;). Thirty-seven of the 85 selected papers were review articles.

Epidemiology
Most reports agree that nursemaid’s elbow is a frequent injury among children.^4,8-10 Unfortunately, published population-based incidence rates are scarce; only 1 article gives an occurrence rate in the total population—1.2%.¹¹ Most epidemiologic data are derived from case series, which show a predominance of injury among girls and to the left arm. Most cases occur at a median age of about 2 years.^2-5,8

Pathology
The many synonyms of nursemaid’s elbow reflect a once obscure understanding of its pathology. Among initial reports from the 1800s, the focus was on determining whether the injury occurred at the wrist or the elbow.¹² Subsequent studies showed that the mechanism of injury usually is a tug on the pronated arm^5,13-16 of young children (who have relatively lax tissue), thereby pulling the radius through the annular ligament,^13-15 which may partially tear and (with the meniscoid synovial fold) become entrapped between the radial head and the capitellum.¹⁵ Most commonly a parent or other caregiver is holding the child by the hand while walking and suddenly pulls the child away from a dangerous situation or merely drags the child up a curb or a step.¹

Diagnosis
We found no clinical studies that assessed the value of physical examination or history taking. The only studies relevant to diagnosis discussed radiography.

FAST TRACK

The cause of injury is usually a tug on the arm; the child then holds the arm slightly flexed and pronated.

Nursemaid’s elbow is an easily recognized diagnosis based on the history and physical examination.¹⁷ Still, it seems many physicians do not recognize the condition.^4-6 Typically, a parent reports that the child cried out after a pull on the arm and then refused to use the arm, holding it slightly flexed and pronated.¹⁸ Pain may be felt only at the wrist or shoulder.^3,18 Occasionally, a snap or click is heard when the accident happens.⁵ The elbow can usually be flexed and extended, but the child resists supination of the forearm, which causes pain in the elbow. There is no swelling or bruising.¹⁹