Podcast #132 - Nursemaid's Elbow

Radial head subluxation, commonly referred to as nursemaid's elbow, is a common condition.  In this post we talk about how to diagnose and manage this condition in a timely and effective manner.

Housekeeping
Thank you WEMSA for having TOTAL EM come and speak.  Make sure to check the next podcast at Wisconsin Dells, Wisconsin in November 2019.

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Epidemiology and Pathology
This pathology usually occurs in children 1-4 years of age and frequently during the second year of life which makes the diagnosis sometimes a little more difficult.  It occurs as the annular ligament becomes interposed between the radial head and cepitellum usually after sudden, longitudinal traction while the elbow is extended and the forearm pronated.  This decreases with time as the annular ligament becomes thicker and stronger at the distal attachment.  Below is an image that demonstrates this pathology on the right and a normal elbow on the left.

Diagnosis
The diagnosis is usually clinical.  Think of a patient not wanting to move their arm after a sudden event.  Usually, they hold their elbow with some flexion and the forearm pronated.  Tenderness is often minimal and located at the lateral aspect of the elbow.  With some encouragement they may be able to move the rest of the extremity and even perform flexion and extension of the elbow.  However, with supination or further pronation, they will cry and try to protect the extremity.

Imaging
In most cases, imaging is not necessary.  X-rays are rarely helpful and will be normal.  Sometimes during the process of obtaining the x-rays they will be reduced.  X-rays are beneficial if there are concerns regarding other injuries such as a fracture being more likely.  However, ultrasound can play a potential role especially if the diagnosis is inconclusive by physical exam.  There is an article detailing the technique and various findings that appear in this condition.

Differential Diagnosis
It is worth remembering there are other potential causes such as fracture, septic arthritis, radial head dislocation, and forearm synostosis.

Technique
The main approach is closed reduction, but rarely it needs open reduction.  Mainly, this is for chronic, symptomatic subluxations that are not reduced with a closed technique.  Supination can be used which involves holding the arm supinated and the elbow maximally flexed.  In both that technique and the hyperpronation technique pressure is applied over the radial head where a palpable click is often felt.  For hyperpronation the forearm is held flexed but can be extended at the elbow as significant pronation is placed holding the wrist.  Here is a quick video from the Merck Manual that goes over both methods.  Usually the patient cries during the technique but shortly afterward should be fully using the upper extremity without difficulty.  If pain persists x-ray should be considered.

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