Nursemaid's elbow is the most common upper extremity injury in children under 5 years of age, caused by subluxation of the radial head through the annular ligament. [1] It is a clinical diagnosis that responds dramatically to bedside reduction, typically requiring no imaging or labs.
1. History
- Key mechanism: Sudden longitudinal traction on an extended, pronated arm — adult pulling child up a curb, lifting by the arms, swinging by the hands, or child pulling away from caregiver [1-2]
- Nonaxial traction mechanisms account for ~17–35% of cases: falls (57% of non-pull cases), direct blow to elbow, rolling over the arm [2-3]
- Sudden onset of crying followed by refusal to use the affected arm
- A snap or click may have been heard at the time of injury [1]
- Median age at presentation: 2.0–2.5 years; most common in ages 1–4 [1][4]
- Left arm predominance (~60%) [1][5]
- Female predominance (~59%) [5]
- Important negatives: No fall from height, no swelling, no deformity, no preceding fever or illness
2. Alarm Features
- Swelling, deformity, or point tenderness → suspect fracture (supracondylar fracture is the key cannot-miss) [4][6]
- Nonambulatory infant (<6 months) with arm immobility → obtain radiographs before reduction; consider non-accidental trauma [7]
- Inconsistent or absent history of injury, especially in very young infants → raises concern for child abuse [7-8]
- Failure of reduction after 2–3 attempts → consider occult fracture or alternative diagnosis [9]
- Fever, warmth, erythema → consider septic joint or osteomyelitis [4]
- Neurologic deficits (weakness beyond pain-limited guarding) → consider brachial plexus injury or acute flaccid myelitis [10]
3. Medications
- No medications are routinely needed — successful reduction provides immediate pain relief
- Acetaminophen (15 mg/kg) or ibuprofen (10 mg/kg) may be given for comfort if the child remains fussy post-reduction or if there is a delay in presentation
- No analgesics or sedation are required for the reduction maneuver itself
- Avoid unnecessary opioids in this population
4. Diet
- Not directly applicable
- Ensure the child is well-hydrated and comfortable; no dietary restrictions
5. Review of Systems
- MSK: Any prior episodes of pulled elbow? Pain in wrist or shoulder (referred pain is common)? [1]
- Neuro: Any weakness, numbness, or tingling in the hand/fingers?
- Constitutional: Fever, weight loss, night sweats (to rule out infection or malignancy)?
- Skin: Bruising, swelling, or skin changes over the elbow or arm?
- General: Is the child otherwise well? Recent illness (viral prodrome preceding acute flaccid myelitis)?
6. Collateral History and Family History
- Who was with the child when the injury occurred? Identify the caregiver and specific mechanism [2]
- Male caregivers more commonly involved in swinging/lifting/wrestling mechanisms; female caregivers more commonly involved in child pulling away or tripping [2]
- Prior episodes of nursemaid's elbow — recurrence rate is approximately 46% [11]
- Family history of connective tissue disorders (e.g., Ehlers-Danlos) may predispose to recurrent subluxation
- Social context: Assess for any concerns regarding non-accidental injury, particularly in nonambulatory infants or when history is inconsistent [7-8]
7. Risk Factors
- Age 1–4 years (peak ~2–2.5 years) [1][5]
- Female sex (59% of cases) [5]
- Left arm (60%) [5]
- Prior episode of nursemaid's elbow (strongest predictor of recurrence) [11]
- Recurrence more likely in males [12]
- Activities involving arm traction: swinging by hands, lifting by arms, pulling child up steps [2]
- Ligamentous laxity in young children (annular ligament is less developed)
8. Differential Diagnosis
- Supracondylar humerus fracture — most dangerous mimic; look for swelling, point tenderness, posterior fat pad sign on X-ray [4][6][13]
- Other elbow fractures (lateral condyle, medial epicondyle, olecranon) — swelling and point tenderness distinguish from nursemaid's elbow
- Forearm fracture (buckle/torus, greenstick) — especially in nonambulatory infants where nursemaid's elbow is unlikely [7]
- Soft tissue injury/contusion — 13% of upper extremity immobility in young children [4]
- Septic arthritis / osteomyelitis — fever, warmth, erythema; consider in infants <6 months [4]
- Brachial plexus injury (Erb palsy) — typically neonatal or post-traumatic
- Non-accidental trauma — always consider in atypical presentations, nonambulatory infants, or inconsistent history [7-8]
9. Past Medical History
- Prior episodes of nursemaid's elbow (up to 46% recurrence) [11]
- Connective tissue disorders
- History of fractures or skeletal abnormalities
- Birth history (brachial plexus injury)
- Developmental milestones (ambulatory status is relevant — nursemaid's elbow is uncommon in nonambulatory infants) [7]
10. Physical Exam
- Classic posture: Arm held at the side, slightly flexed at the elbow, forearm pronated; child refuses to use the arm [1][9]
- No swelling, bruising, or deformity — presence of any of these should prompt radiographic evaluation [1][4]
- Passive flexion and extension of the elbow are usually tolerated, but forearm supination/pronation causes pain and resistance [1]
- Pain may be localized to the elbow, wrist, or shoulder [1]
- Palpate the entire upper extremity: clavicle, humerus, forearm, wrist — point tenderness suggests fracture [4]
- Assess distal neurovascular status (radial pulse, capillary refill, finger movement)
- Key distinguishing features (multivariate analysis): Decreased arm movement + absence of swelling + pull mechanism → correlates with nursemaid's elbow; point tenderness + swelling → correlates with fracture [4]
11. Lab Studies
- No labs are indicated for a classic presentation of nursemaid's elbow
- If septic arthritis or osteomyelitis is suspected: CBC, CRP, ESR, blood cultures
- If non-accidental trauma is suspected: skeletal survey, and labs per institutional child abuse protocol
12. Imaging
- Imaging is NOT routinely required — nursemaid's elbow is a clinical diagnosis [1][5][9]
- Radiographs are typically normal in nursemaid's elbow (no specific radiographic finding)
- Obtain radiographs when:
- Swelling, point tenderness, or deformity is present
- Mechanism is atypical or unclear
- Child is older (>6 years)
- Nonambulatory infant [7]
- Reduction fails after 2–3 attempts [9]
- Radiographs were obtained in 28.5% of ED visits for nursemaid's elbow, with wide hospital variation (19.8–41.7%); missed fractures were rare at 0.3% [5]
- POCUS is emerging as a useful adjunct in atypical cases or to confirm successful reduction (synovial fringe enlargement sign, "partial eclipse sign") [6][14-15]
- Type I supracondylar fractures can mimic nursemaid's elbow on exam; POCUS with dorsal fat pad sign evaluation has 100% sensitivity and specificity in one study [6]
13. Special Tests
- Point-of-care ultrasound (POCUS):
- Dorsal fat pad sign (FPS) → positive in fractures, negative in nursemaid's elbow [6]
- Synovial fringe enlargement (SFE) → positive in nursemaid's elbow, absent in fractures [6]
- "Partial eclipse sign" on axial view → present before reduction, disappears after successful reduction [15]
- Two-plane POCUS (dorsal + ventral longitudinal) achieved 100% sensitivity/specificity for distinguishing nursemaid's elbow from fracture in one prospective study [6]
- No validated scoring systems specific to nursemaid's elbow
14. ECG
15. Assessment
Nursemaid's elbow is a benign, self-limited condition when promptly reduced. The typical presentation — a child aged 1–4 years with sudden refusal to use the arm after a pulling mechanism, no swelling, and no deformity — is highly reliable for clinical diagnosis. [1][4] Approximately one-third of cases present with a nonclassical history (fall, twist, unknown mechanism), which should not preclude the diagnosis if the exam is otherwise consistent. [3][16] Complications are exceedingly rare; the primary concern is missed fracture (0.3% of cases). [5]
16. Treatment Plan
Reduction Technique — Hyperpronation (preferred first-line):
- Stabilize the elbow at 90° flexion with one hand, thumb over the radial head
- With the other hand, firmly hyperpronation the forearm at the wrist
- A palpable click over the radial head indicates successful reduction
- First-attempt success rate: ~90% vs. ~75% for supination-flexion [1][17-18]
Supination-Flexion (alternative)
- Stabilize the elbow with one hand, thumb over the radial head
- Supinate the forearm fully, then flex the elbow rapidly
- First-attempt success rate: ~75% [1][17]
Meta-analytic evidence from the 2017 Cochrane Review (8 RCTs, 811 children) and a 2025 updated meta-analysis (11 RCTs) consistently demonstrates that hyperpronation has significantly lower first-attempt failure rates (9.2–9.8% vs. 24.2–26.4%; RR 0.35, 95% CI 0.25–0.50; NNT = 6). [1][17-18]
Post-reduction
- Observe for 10–15 minutes; the child should begin using the arm spontaneously
- Offering a toy or snack to encourage arm use is a practical assessment tool
- If the first attempt fails, repeat the same maneuver once; if still unsuccessful, try the alternate technique [9]
- If 2–3 total attempts fail, splint the arm in a posterior splint with the elbow at 90° and arrange follow-up within 1–2 days [9]
17. Disposition
- Discharge after successful reduction once the child demonstrates normal arm use (typically within 5–15 minutes)
- No immobilization is needed after successful reduction
- Splint and refer if reduction is unsuccessful after 2–3 attempts [9]
- Obtain radiographs before discharge if reduction fails, if there is any concern for fracture, or if the presentation is atypical [5]
- Orthopedic consultation for: irreducible subluxation, suspected fracture, recurrent episodes requiring further evaluation [19-20]
- Child protective services involvement if non-accidental trauma is suspected [7-8]
18. Follow Up / Return Precautions
- No routine follow-up is needed after successful reduction in a classic presentation
- Counsel caregivers to avoid pulling or lifting the child by the hands/wrists/forearms — this is the single most important preventive measure [2][9]
- Advise that recurrence is common (~46% of children with one episode will have another); the condition resolves as the child grows and the annular ligament matures (typically by age 5–6) [11]
- Return precautions — seek immediate care if:
- The child stops using the arm again
- Swelling, bruising, or deformity develops
- Fever develops
- The child is inconsolable or the arm appears worse
- Expected recovery: Full, immediate return to normal function after successful reduction; no long-term sequelae [4]
- For recurrent cases (≥3 episodes), consider referral for orthopedic evaluation and possible orthosis/targeted exercises [20]
References
1. Manipulative Interventions for Reducing Pulled Elbow in Young Children. — Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom-Smit LW, Koes BW. The Cochrane Database of Systematic Reviews. 2017.
2. No Longer a "Nursemaid's" Elbow: Mechanisms, Caregivers, and Prevention. — Rudloe TF, Schutzman S, Lee LK, Kimia AA. Pediatric Emergency Care. 2012.
3. Nonaxial Traction Mechanisms of Nursemaid's Elbow. — Li N, Khoo B, Brown L, Young T. Pediatric Emergency Care. 2021.
4. Upper-Extremity Impairment in Young Children. — Schutzman SA, Teach S. Annals of Emergency Medicine. 1995.
5. Management and Outcomes of Children With Nursemaid's Elbow. — Genadry KC, Monuteaux MC, Neuman MI, Lipsett SC. Annals of Emergency Medicine. 2021.
6. Two- Plane Point of Care Ultrasonography Helps in the Differential Diagnosis of Pulled Elbow. — Varga M, Papp S, Kassai T, et al. Injury. 2021.
7. Suspected Radial Head Subluxation in Infants: The Need for Radiologic Evaluation. — Hanes L, McLaughlin R, Ornstein AE. Pediatric Emergency Care. 2021.
8. Evaluating Young Children With Fractures for Child Abuse: Clinical Report. — Haney S, Scherl S, DiMeglio L, et al. Pediatrics. 2025.
9. Pulled Elbow in Children. — Yamanaka S, Goldman RD. Canadian Family Physician Medecin De Famille Canadien. 2018.
10. Acute Flaccid Myelitis: Cause, Diagnosis, and Management. — Murphy OC, Messacar K, Benson L, et al. Lancet. 2021.
11. Parental Questionnaire Study Showed That Annular Ligament Displacement Was Common in Three-Year-Old Children and Almost a Half Had Reoccurring Episodes. — Kimura M, Taketani T, Kurozawa Y. Acta Paediatrica. 2018.
12. Radial Head Subluxation: Factors Associated With Its Recurrence and Radiographic Evaluation in a Tertiary Pediatric Emergency Department. — Wong K, Troncoso AB, Calello DP, Salo D, Fiesseler F. The Journal of Emergency Medicine. 2016.
13. Elbow Pain in Pediatrics. — Crowther M. Current Reviews in Musculoskeletal Medicine. 2009.
14. Point-of-Care Ultrasonography to Assist in the Diagnosis and Management of Subluxation of the Radial Head in Pediatric Patients: A Case Series. — Güngör F, Kılıç T. The Journal of Emergency Medicine. 2017.
15. The Usefulness of Dynamic Ultrasonography in Nursemaid's Elbow: A Prospective Case Series of 13 Patients Reconsideration of the Pathophysiology of Nursemaid's Elbow. — Tsai CC, Chiang YP. Journal of Pediatric Orthopedics. 2023.
16. The Relationship Between the Bevel of the Radial Head Epiphysis and the Posterior Synovial Fringe During Rotation of the Elbow: An Ultrasonography Study With Possible Implications Regarding the Pathophysiology of Nursemaid's Elbow. — Tsai CC, Chiang YP. Journal of Pediatric Orthopedics. 2023.
17. Comparative Effectiveness of Supination-Flexion and Hyperpronation Maneuvers in Radial Head Subluxation: A Systematic Review and Meta-Analysis. — Aksel G, Çorbacıoğlu ŞK, Akoğlu H, İslam MM. C The American Journal of Emergency Medicine. 2025.
18. Comparison of Supination/Flexion Maneuver to Hyperpronation Maneuver in the Reduction of Radial Head Subluxations: A Randomized Clinical Trial. — Aksel G, Küka B, İslam MM, et al. C The American Journal of Emergency Medicine. 2025.
19. Irreducible (Nursemaid's) Pulled Elbow: A Literature Review of Sonographic Diagnostic Criteria. — Colucci P, Tracey O, Jaramillo D, Scher D. Pediatric Radiology. 2025.
20. A Case Report of Recurrent Annular Ligament Displacement in a Pediatric Patient. — Van Oort C. Journal of Hand Therapy : Official Journal of the American Society of Hand Therapists. 2025.