Practice Essentials
Nursemaid elbow, also known as “radial head subluxation” or simply “pulled elbow”, is the most common upper-limb injury in children under the age of 6. [1, 2] It is typically an easily treatable condition. Correct diagnosis is the primary challenge to the physician.
Signs and symptoms
Parents often give a history of a young child with no history of trauma who suddenly refuses to use an arm.
Physical examination commonly reveals an anxious child who is protective of the affected arm. The forearm is usually held in incomplete extension, and the forearm is partially pronated.
See Presentation for more detail.
Diagnosis
Nursemaid elbow is often indistinguishable from a healthy elbow on radiography.
See Workup for more detail.
Management
Treatment consists of manipulating the child's arm (closed reduction) so that the annular ligament and radial head return to their normal anatomic positions.
See Treatment and Medication for more detail.
Patient education
Most parents appreciate knowing that reoccurrence can occur in 1/5-1/4 of patients.
Pathophysiology
The etiology is movement of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn. As children age, the annular ligament strengthens. In children over the age of 5, subluxation of the radial head is prevented by a thicker and stronger attachment between the annular ligament and the periosteum of the radial neck. [3] As a result, nursemaid’s elbow occurs less often.
A nursemaid’s elbow (NE) is a low-energy trauma often occurring from brisk axial traction of the forearm, often by an adult who holds the child’s hand as the child pulls away. Other causes of injury include falls, wrestling, and abuse. [4]
The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm. The common belief that nursemaid elbow is due to children having a radial head smaller than the radial neck is incorrect.
Etiology
Axial traction is the most common cause of nursemaid elbow. A fall is the second most common mechanism of injury.
Infants have been reported with nursemaid elbow after rolling over or being assisted to roll over. [5] However, nursemaid elbow is an uncommon finding in nonambulatory infants. [6]
Epidemiology
United States statistics
The annual rate of radial head subluxation per 10,000 children aged 6 years and younger increased from 5.18 in 2004 to 7.69 in 2018. The overall annual rate during the study period was 6.03 per 10,000 children. [7]
Sex- and age-related demographics
Sex
Published case series report a slight predominance in females. [8, 9]
Published case series report a slight left arm predominance in both males and females. [8, 9]
A study by Wong et al that reviewed 246 pediatric ED visits for radial head subluxation reported that recurrence was more likely in male patients. [10]
Age
Nursemaid elbow most commonly occurs in children aged 1-4 years. However, it has been reported in patients as young as 4 months and as old as 31 years. [11]
A study that examined the epidemiological description of radial head subluxation found that the average age of children presenting with nursemaid's elbow was 28.6 months. [9]
