Pulled elbow reduction

Synonyms: Nursemaid’s elbow, Radial head subuluxation, Elbow subluxation

Age: Commonly 1-4 years

• After 5 years of age, the attachment of the annular ligament to the neck of the radius strengthens
• Enlargement of the proximal radial epiphysis with growth may also improve stability

Presentation:

1. History of pull may be absent in ~50% cases
2. Not using the affected limb (Pseudoparalysis)
3. Elbow in extension and the forearm in pronation
4. Distressed only on elbow movement
5. No swelling, deformity or bruising of the elbow or wrist
6. On palpation tenderness is usually absent
7. Marked resistance and pain with supination of the forearm

Reduction of pulled elbow produces immediate relief. It is necessary to rule out other causes if reduction attempt fails to produce relief.
X-ray: rule out effusion, fracture and true dislocation
CBC, CRP, ESR: rule out infection

Pathoanatomy:

Reduction Maneuvers

Supination and Flexion maneuver (Classic method): Following steps are carried out in one smooth motion 1Pfenninger and Fowler’s Procedures for Primary Care E-Book By Grant C. Fowler

1. Hold elbow with non-dominant hand with either thumb or 2nd and 3rd fingers exerting constant gentle pressure over the radial head in medial direction
2. With dominant hand, apply slight distal traction with supination at wrist.
3. Rapidly raise the forearm of the child towards arm and flex the elbow >90 degrees.
4. Click may be felt at the radial head

Pronation and Flexion maneuver (Hyperpronation method): Following steps are carried out in one smooth motion

1. Hold elbow as mentione above
2. Instead of supinating, hyperpronate the wrist with slight distal traction (this may be all that is needed; continue to next step if reduction not achieved)
3. Perform rapid flexion at elbow
4. Click may be felt at the radial head

Some studies have shown hyperpronation method to be more successful and less painful compared to supination and flexion method in achieving reduction of pulled elbow.

Success of reduction:

1. Child should be using forearm normally within 30 minutes
2. If not, repeat manipulation can be attempted using a technique alternative to the first one

X-ray of radial head subluxation may be normal or may show increased radio-coronoid distance on the lateral x-ray. The radiocapitellar line may be displaced by more than 3mm. The radiographer may have reduced the pulled elbow when supinating the elbow for the AP film.

What to do if it’s an “irreducible” pulled elbow?

1. Rule out other causes (Occult septic elbow or fracture)
2. One author recommends – resting the arm in a sling and spontaneous reduction would usually occur within 48 hours. 2Practical fracture treatment, 5th Ed. (McRae and Esser)
3. Other author recommends – casting the child in elbow flexed in 100 degrees and forearm in full supination for 3 weeks. 3https://thoracickey.com/elbow-proximal-radius-and-ulna/
4. In cases where annular ligament has slipped passed radial equator into the radiocapitellar joint – surgical exploration may be required.