Nursemaid's Elbow (Radial Head Subluxation)

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Nursemaid's Elbow, also known as Radial Head Subluxation, is a common injury in young children, particularly those under five years old. It occurs when the radius (a bone in the forearm) slips out of its normal position at the elbow joint, specifically from the annular ligament that holds it in place. This usually happens due to a sudden pull on the child's arm, causing pain and difficulty moving the affected limb.

Aetiology

Nursemaid's Elbow is typically caused by a sudden or forceful pulling on a child's arm, which leads to the subluxation of the radial head. Common scenarios that can cause this injury include:

• Lifting or swinging a child by their hands or arms.
• Sudden pulling of the arm, such as when a child is yanked to prevent a fall.
• Falls where the child lands on an outstretched hand.

Pathophysiology

In Nursemaid's Elbow, the radial head slips out from under the annular ligament, which normally keeps it in place within the elbow joint. In young children, the annular ligament is more flexible and the radial head is not fully developed, making it easier for the radial head to become dislodged. Once the radial head is out of place, the child experiences pain and is unable to move the arm properly. The injury does not typically cause long-term damage if treated promptly.

Risk Factors

• Age: Children under five years old are most at risk, as their bones and ligaments are still developing and are more prone to this injury.
• Activities: Activities involving pulling or lifting by the arms (e.g., swinging or yanking).
• History of Nursemaid's Elbow: Children who have had this injury before are at increased risk of recurrence.
• Falls: Falls that involve landing on an outstretched arm can increase the risk.

Signs and Symptoms

The signs and symptoms of Nursemaid's Elbow typically appear immediately after the injury:

• Sudden refusal to use the arm: The child may hold the affected arm still and refuse to move it due to pain.
• Arm held in a slightly flexed position: The child may hold their arm close to their body with the elbow slightly bent.
• Pain: The child may experience pain in the elbow or forearm, especially when attempting to move the arm.
• No visible swelling or deformity: Unlike fractures or dislocations, Nursemaid's Elbow does not usually cause swelling or obvious deformity.

Investigations

Nursemaid's Elbow is usually diagnosed based on the clinical presentation and history of the injury. In most cases, no imaging is required. However, if there is uncertainty about the diagnosis or concern about a fracture or other injury, the following may be considered:

• Clinical examination: A physical examination that focuses on the child's ability to move the arm and the location of tenderness.
• X-ray: X-rays are not typically needed unless there is concern about a fracture or other bony injury.

Management

The treatment for Nursemaid's Elbow involves a simple manual reduction technique to reposition the radial head back into place. The following are common management steps:

Reduction Techniques:

• Supination-flexion method: The healthcare provider gently supinates (turns the forearm outward) while flexing the elbow. This usually results in an audible or palpable click as the radial head moves back into place.
• Hyperpronation method: The forearm is pronated (turned inward) while the elbow is extended, which also achieves reduction.

Post-Reduction Care:

• Most children experience immediate relief after the reduction and will begin using the arm normally within minutes.
• If the child does not regain normal use of the arm shortly after the reduction, further evaluation may be required to rule out other injuries.
• Parents should be educated on avoiding pulling or lifting the child by their arms to prevent recurrence.

References

1. NICE (2024). Radial Head Subluxation: Diagnosis and Management. Available at: NICE Guidance
2. Royal College of Paediatrics and Child Health (2023). Nursemaid's Elbow: A Paediatric Guide. Available at: RCPCH
3. British Medical Journal (BMJ). (2022). Radial Head Subluxation in Children: Clinical Review. Available at: BMJ