Radial Head Subluxation (Nursemaid’s Elbow)

Radial head subluxation, also known as nursemaid’s elbow or babysitter’s elbow, is a frequent injury seen in children under 4 years of age and describes the subluxation of the radial head under the annular ligament at the elbow. The injury primarily occurs when a child is pulled, swung, or lifted by 1 arm. Patients present holding their injured upper limb in a guarded and pronated position. Diagnosis is made clinically and the condition is managed by a closed-reduction maneuver. Prognosis is excellent when diagnosed in a timely manner.

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Overview

Definition

Radial head subluxation, also known as nursemaid’s elbow or babysitter’s elbow, describes the subluxation of the radial head under the annular ligament due to longitudinal traction on the forearm.

Epidemiology

  • Affects 20,000 children per year in the United States
  • Most commonly occurs in children aged 1–4 years 
  • Most common upper limb injury in children < 6 years of age
  • The left arm tends to be injured more often.
  • Girls are more commonly affected.

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Pathophysiology

Radial head subluxation occurs when the child is lifted up by the arms with resultant axial traction of the forearm; e.g., while the child is being swung, lifted, or pulled by 1 arm. 

Axial traction mechanism:

  • Pronated forearm undergoes axial traction while the elbow is extended.
  • With axial traction, the head of the radius slips under the annular ligament.
  • The annular ligament becomes interposed between the capitellum and the radial head.
  • As children age, the annular ligament thickens and nursemaid’s elbow becomes less likely to occur.

Other possible mechanisms:

  • Falling onto outstretched arm
  • Twisting of forearm
Difference normal elbow and nursemaid’s elbow

Difference between a normal elbow and a nursemaid’s elbow

Image by Lecturio. License: CC BY-NC-SA 4.0

Clinical Presentation and Diagnosis

History

History and presentation often lead to the diagnosis:

  • Young toddler refusing to use arm
  • Often associated with history of longitudinal traction:
    • Young child moves suddenly in opposite direction while holding adult’s hand.
    • Young child is lifted up by arms.

Physical examination

The entire affected upper limb/clavicle should be examined.

  • Patient is often anxious and protective of injured arm.
  • Injured upper limb is held in slightly flexed, pronated position.
  • Patients are unable or unwilling to supinate their arm.
  • Signs of trauma (e.g., ecchymosis, edema, warmth) or neurovascular compromise are absent; if present, other diagnoses should be considered.
  • If there is clinical suspicion of child abuse, a complete physical examination should be performed.
  • If radial head spontaneously reduces prior to examination, patients may be asymptomatic.

Diagnosis

History and physical examination with typical findings are sufficient to diagnose. Imaging may be useful when diagnostic challenges occur with atypical presentations or unknown history.

X-ray

  • Rarely indicated with typical presentation
  • Useful in evaluation of other diagnoses (e.g., fracture, congenital elbow dislocation, infectious etiology)
  • A Salter-Harris type I fracture of distal humerus may present with normal radiographs.

Management and Prognosis

Management

Closed reduction of a nursemaid’s elbow is the procedure of choice. The clinician must be certain there are no fractures prior to manipulation.

Supination/flexion technique:

  • Warn caregivers that the maneuver will hurt and the child will likely cry.
  • Child can be seated in parent’s or caregiver’s lap.
  • Fully extend and supinate elbow and then take elbow into flexion.
  • This procedure is done while maintaining slight pressure over the radial head; often, the provider will feel a “click” in the elbow.
  • Typically, the child will be moving the arm normally within 15 minutes.

Hyperpronation technique:

  • Warn caregivers that the maneuver will hurt and the child will likely cry.
  • Child can be seated in parent’s or caregiver’s lap.
  • While applying mild pressure over the radial head, the provider holds the elbow in a flexed position and hyperpronates the forearm.
  • A click may be felt when displacement is reduced.
  • Typically, the child will be moving the arm normally within 15 minutes.

Patients who fail the initial reduction maneuver:

  • Reconsider the diagnosis.
  • If there are no signs of fracture, reduction attempt may be repeated.
  • If unable to reduce or if diagnosis is in question, consider a splint and orthopedic referral.

Prognosis

  • Prognosis is excellent when reduced in a timely manner.
  • Recovery is immediate after reduction.
  • Recurrence rate: approximately 20%

Differential Diagnosis

  • Child abuse: an act or failure to act that results in harm to a child’s health or development. Child abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. 
  • Greenstick fracture: partial-thickness fracture that involves a complete break of cortex and periosteum on only 1 side of the bone. Termed “greenstick” as it resembles the break in a live, “green” twig, where 1 side of the stick remains intact. High risk for refracture and therefore should be completely immobilized. Rarely requires reduction, but should be managed cautiously to prevent malunion or angulation deformities, and often should be referred for orthopedic follow-up.
  • Buckle or torus fracture: fracture affecting growing metaphyseal bone secondary to compression load, where bone buckles or compresses. Generally considered a stable fracture. Treated by immobilization and has good a prognosis.
  • Supracondylar fracture: complete fracture affecting distal humerus after falling on outstretched hand. Commonly fractures of the elbow in children. Requires immediate orthopedic consultation, as many cases are associated with neurovascular injury and require surgical intervention. 

References

  1. Nardi, N. M., Schaefer, T. J. (2021). Nursemaid elbow. StatPearls. Retrieved May 10, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK430777/
  2. Welch, R., Chounthirath, T., Smith, G. A. (2017). Radial Head Subluxation Among Young Children in the United States Associated With Consumer Products and Recreational Activities. Clin Pediatr (Phila). 56(8), 707–715. https://pubmed.ncbi.nlm.nih.gov/28589762/
  3. Macias, C. G., Bothner, J., Wiebe, R. (1998). A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 102(1), e10. https://pubmed.ncbi.nlm.nih.gov/9651462/
  4. Genadry, K. C., et al. (2021). Management and Outcomes of Children With Nursemaid’s Elbow. Ann Emerg Med. 77(2), 154–162. https://pubmed.ncbi.nlm.nih.gov/33127100/

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