Reduction of Nursemaid’s Elbow (Radial Head Subluxation)

Radial head subluxation is frequently referred to as “nursemaid’s elbow”

The annular ligament of the radius displaces into the radiocapitellar articulation (FIGURE 92.1A)

A common injury in children between the ages of 2 and 5 years, after which the annular ligament strengthens and the injury becomes uncommon

INDICATIONS

Clinical suspicion of a nursemaid’s elbow based on:

Refusal to use affected arm

Typical posture: Affected arm adducted or held at the side, with the elbow slightly flexed and forearm pronated. The child is usually in no distress unless the arm is moved.

Suggestive mechanism of injury

CONTRAINDICATIONS

Gross deformity, swelling, or significant point tenderness suggesting fracture

General Basic Steps

Analgesia (if indicated)

Patient preparation

Reduction

Reevaluation

TECHNIQUE

Patient Preparation

Caretaker/parent holds child in her/his lap, restraining the unaffected arm

Hyperpronation Method (FIGURE 92.1B)

With one hand, encircle the elbow with the thumb over the region of the radial head, keeping the elbow flexed at 90 degrees

With the other hand, grasp the wrist, and firmly pronate at the wrist

Supination/Flexion Method (FIGURE 92.1C and D)

With one hand, encircle the elbow with the thumb over the region of the radial head, keeping the elbow position in some flexion

With the other hand, grasp the wrist and apply gentle traction before supination

In one motion, supinate the forearm fully and flex the elbow to the ipsilateral shoulder

Postprocedure

Reevaluate child in 10 to 15 minutes to note use of arm. The child will generally regain use of the arm quickly.

If the child has not regained use of the arm within 10 to 15 minutes of attempted reduction and no click was detected during procedure, the procedure should be repeated

Radiography should be performed if the child has not regained use of arm after a reasonable time and no click was detected

FIGURE 92.1 A–D: Nursemaid’s elbow. (From Cimpello LB, Deutsch RJ, Dixon C, et al. Illustrated techniques of pediatric emergency procedures. In: Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1832.)

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