Nursemaid's Elbow

OnLIne EXClUSIVE Marjolein Krul, MD; Johannes C. van der Nursemaid’s elbow: Wouden, MD; François G. Schellevis, MD; Lisette W.A. van Its diagnostic clues and preferred Suijlekom-Smit, MD; Bart W. Koes, MD means of reduction Department of General Practice, Erasmus University Medical Center, Rotterdam, This systematic review revealed that correcting the The Netherlands (Drs. Krul, van der Wouden, and Koes); injury with pronation is more successful and less painful Department of General Practice, VU University Medical Center, than supination. Utrecht, The Netherlands (Dr. Schellevis); and Sophia Children’s Hospital, Rotterdam (Dr. van Suijlekom-Smit) ursemaid’s elbow—sudden subluxation of the [email protected] PRACTICE radial head—usually results from forcible traction RECOmmENDATIONS The authors reported to a child’s pronated hand or wrist, with the elbow no potential conflict of interest › N ®1 relevant to this article. Nursemaid’s elbow typically extended. Ironically,Dowden this can Health occur when Mediaa parent tries to occurs with a sudden pull on maneuver a child away from perceived danger, and the child a child’s arm. Reserve radi- experiences pain and acute loss of function of the affected ography for uncertain casesCopyright limb.For2 personal use only in which you need to exclude Nursemaid’s elbow reportedly occurs frequently among more severe injuries. B children,3,4 and thus we would expect to encounter it often in › Consider reducing primary care. However, this condition receives little attention nursemaid’s elbow by rapid in medical training or in the literature, and many physicians pronation of the forearm, do not recognize it.4–6 which has been shown to be less painful and more effective In this article we describe the epidemiology, underlying than supination. A pathology, diagnosis, and treatment of nursemaid’s elbow, based on a systematic review of the current literature. Strength of recommendation (SOR) A Good-quality patient- oriented evidence Methods B Inconsistent or limited-quality patient-oriented evidence Literature search C Consensus, usual practice, Using PubMed and Embase, we conducted a literature search opinion, disease-oriented evidence, case series for articles published in Dutch, English, German, or French from 1966 through July 2007 on the topic of nursemaid’s elbow in children. We used as search terms all known synonyms for nursemaid’s elbow—eg, radial head subluxation, partial epiphyseal separation of the radial head, pulled elbow, baby- sitter’s elbow, curbstone fracture, etc. Publications cited in our initial search were also checked for relevance. Articles were reviewed and judged independently by 2 authors (M.K. and J.C.v.d.W.). Articles we selected focused on proximal radial subluxation. We excluded articles on distal radial subluxation and luxation of the radius. The 2 reviewers assessed the quality of articles on treat- JFPONLINE.COM VOL 59, NO 1 | JANUARY 2010 | THE JOURNAL OF FAMILY PRACtICE E5 For mass reproduction, content licensing and permissions contact Dowden Health Media. ment using the validated Jadad score,7 where- arm5,13–16 of young children (who have rela- in a maximum of 5 points may be awarded: tively lax tissue), thereby pulling the radius • 1 point if the study is described as through the annular ligament,13–15 which may randomized: partially tear and (with the meniscoid synovi- ▶ 1 point added for appropriate method al fold) become entrapped between the radial of randomization head and the capitellum.15 Most commonly a ▶ 1 point deducted for inappropriate parent or other caregiver is holding the child randomization by the hand while walking and suddenly pulls • 1 point if the study is described as the child away from a dangerous situation or double-blind: merely drags the child up a curb or a step.1 ▶ 1 point added for appropriate method of blinding Diagnosis ▶ 1 point deducted for inappropriate We found no clinical studies that assessed the blinding value of physical examination or history tak- • 1 point for a description of withdrawals ing. The only studies relevant to diagnosis dis- or dropouts. cussed radiography. No cutoff limit for Jadad scores was Nursemaid’s elbow is an easily recognized planned as a criterion for exclusion. As it is diagnosis based on the history and physical not possible to treat nursemaid’s elbow in a examination.17 Still, it seems many physicians The cause double-blind fashion, 3 was the highest pos- do not recognize the condition.4–6 Typically, of injury is sible score in our study. a parent reports that the child cried out after usually a tug a pull on the arm and then refused to use the on the arm; arm, holding it slightly flexed and pronated.18 the child then Results Pain may be felt only at the wrist or shoulder.3,18 holds the arm Our literature search produced 368 potentially Occasionally, a snap or click is heard when the slightly flexed relevant papers; of these, 60 met our inclusion accident happens.5 The elbow can usually be and pronated. criteria. The reference lists of selected studies flexed and extended, but the child resists supi- and reviews yielded an additional 25 accept- nation of the forearm, which causes pain in the able papers, each covering various aspects of elbow. There is no swelling or bruising.19 the topic (epidemiology, 19; pathology, 10; di- Children are often referred for radio- agnosis, 10; treatment, 9;). Thirty-seven of the graphic examination with the observation, 85 selected papers were review articles. “refuses to use arm; please x-ray from shoulder to wrist.”20 Radiography is of little help, howev- Epidemiology er, and exposes the child to a dose of ionizing Most reports agree that nursemaid’s elbow is a radiation. Although some studies show small frequent injury among children.4,8–10 Unfortu- significant differences between nursemaid’s nately, published population-based incidence elbow and the normal elbow,21–23 radiographic rates are scarce; only 1 article gives an occur- results generally are reported as normal.4,6,8,24 rence rate in the total population—1.2%.11 (Some commentators assume this may occur Most epidemiologic data are derived from case if the radiology technician repositions the arm series, which show a predominance of injury in an attempt to obtain a true anteroposterior among girls and to the left arm. Most cases oc- projection of the elbow.1,18,25) Restrict radiog- cur at a median age of about 2 years.2–5,8 raphy, therefore, to cases with an unclear history or a history of trauma other than arm pull, Pathology to exclude more severe injuries. The many synonyms of nursemaid’s elbow The role of sonography is not yet clear, but reflect a once obscure understanding of its it may turn out to be a fast and harmless tech- pathology. Among initial reports from the nique for diagnosing uncertain cases.20,25,26 1800s, the focus was on determining whether the injury occurred at the wrist or the elbow.12 Treatment Subsequent studies showed that the mecha- Although no articles have described the natu- nism of injury usually is a tug on the pronated ral course of nursemaid’s elbow, most authors E6 THE JOURNAL OF FAMILY PRACtICE | JANUARY 2010 | VOL 59, NO 1 NURSEMaID’S ELbOW report that it resolves on its own when a child ies report that the pronation method is less moves the arm in supination or pronation. It is painful for the child and less frightening for a so easily treated that parents of children with parent to watch.29–31 Green et al confirmed this recurrent episodes have even been instructed in their randomized trial.32 by phone how to perform the reduction.27 Most articles and textbooks recommend reducing nursemaid’s elbow by a rapid supi- Most compelling finding nation of the forearm, followed by flexion or The highest quality studies were those devoted extension.9,28 However, some articles have to treatment,28,30–33 and the clear conclusion described a pronation method.29 We found from their findings—in contrast to what text- 2 high-quality trials that compared the success books recommend—is that reduction with a rate of the supination method with the pro- pronation maneuver is more often successful nation method.30,31 Researchers conducting than the supination method. Of course more 1 medium-quality trial assessed the dif- studies will be needed before textbooks change ference in pain experienced with these their recommendations. But at least these stud- 2 methods.32 And researchers conducting ies provide helpful guidance now. 1 low-quality trial tried to assess whether splinting after manipulation helps to prevent CORRESpONDENCE recurrences of nursemaid’s elbow.10 Marjolein Krul, MD, Department of General Practice, Room Ff304, Erasmus MC-University Medical Center Rotterdam, PO These trials indicate the pronation meth- Box 1738, 3000 DR Rotterdam, The Netherlands; m.krul@eras- Restrict x-ray use od is more successful. In addition, some stud- musmc.nl to cases with an unclear history or those that are due to trauma References other than an 1. Salter RB, Zaltz C. Anatomic investigations of the mechanism of 18. Asher MA. Dislocations of the upper extremity in children. Or- injury and pathologic anatomy of “nursemaid’s elbow” in young thop Clin North Am. 1976;7:583-591. arm pull. children. Clin Orthop Relat Res. 1971;77:134-143. 19. Hardy RH. Nursemaid’s elbow. J R Coll Gen Pract. 1978;28:224-226. 2. Hagroo GA, Zaki HM, Choudhary MT, et al. Nursemaid’s elbow— 20. Outzen S. Chassaignac-Im Zweifel Diagnose per Sonographie? not the effect of hypermobility of joints.Injury . 1995;26:687-690. Chir Praxis.

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