What is nursemaid elbow? It is the most common injury which is affecting the upper extremity especially in the children. The children are usually younger than 5 years old.
Nursemaid elbow is associated by longitudinal traction which is applied to the extended and pronated arm. Collateral history may include a pull which is sharp on characteristic on the outstretched arm of a child which can occur by lifting the child by the wrist. Any history of the fall may also be associated with nursemaid elbow. Nursemaid elbow is pathologically related to the radial head subluxation. In this scenario, the annular ligament has torn or slips and later interposed between the capitellum and radial head.
The signs and symptoms of nursemaid elbow may include pain sensation with pronation and supination of the forearm as well as flexion of the elbow. The child also may refuse to use the affected arm and the forearm is held close to the trunk with elbow slightly flexed. Patient/ the child may present with minimal swelling to no swelling at all. The point of tenderness /soreness I usually absences in the nursemaid elbow.
The essential steps to achieve the clinical diagnosis of nursemaid elbow may include the classic presentation of the disorder as mention above or the passive use and position of the arm or perform a physical examination to justify the finding.
Radiological test is not routinely performed. Radiological test ( X ray) is used to exclude other injuries that may present. Radiological test ( X ray) is used if the child present with failed reduction, point tenderness, ecchymosis of the elbow , deformity or any swelling of the soft tissue.
The differential diagnosis may include tumour, osteomyelitis, an infection of the joint, dislocation of the elbow and radius as well as fractures of the humerus.
The treatment may include pre hospital treatment, initial stabilization and treatment in the emergency department.
The pre hospital treatment may include ice placed on the injured part of the elbow to reduce the swelling and pain as well as immobilization in a splint or sling to prevent further injury and to facilitate the transport process. It is also very important to assess the distal neurovascular structure.
The sensory, vascular and distal motors are assessed as part of the initial stabilization. In the emergency department, the reduction is performed. There are two common techniques of reduction. The reduction technique may include supination/flexion reduction technique and hyper pronation reduction technique.
In hyper pronation reduction technique, the child’s hand is grasped in a handshake position while the other hand is used to stabilize the elbow which is injured. The forearm is hyper pronated and extended.
In supination /flexion reduction technique the child’s hand is grasped in a handshake position while the injured elbow is stabilized with the other hand. The forearm is fully supinate in a swift and smooth motion while the elbow is flexed.
Successful reduction may be followed by palpable click. However it is not always present. The child may able to use the arm soon after reduction as the procedure is pain free. However, sometimes the child may cry.
It is important to observe if the child is using the affected arm or not in 15 minutes. If the arm is not used in 15 minutes consider second reduction. In second reduction an opposing technique is used. If the second reduction technique appears to be unsuccessful consider radiography studies.
Orthopaedic evaluation is required if the child with splint presented with radiographic abnormalities due to elbow injury such as supracondylar, condylar and displaced fractures.
Orthopaedic follow up in 24- 48 hours and posterior splint are required if no radiological abnormalities detected and attempted reduction is failed.
Post reduction Neuro vascular assessment also should be performed. Family should be warned for neuro vascular compromised.
A medication that is usually given to the child may include 15mg/kg PO every 4 hour of acetaminophen.
In term of follow up, the child is discharged back home, after the child regains unrestricted and full use of the arm. The caregiver/parents are informed not to lift or pull the child by the wrist, forearm and hand. There is an increase incidence of recurrence of nursemaid elbow until the child is finally over 5 to 6 years of age.
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