Episode 975: Nursemaid's Elbow

Sep 22, 2025

Explore the intriguing world of nursemaid's elbow, a common elbow condition in young children caused by sudden tugs on their arms. Learn how to identify it without x-rays, as kids usually just hold their arm close and avoid using it. Discover two reduction techniques: hyperpronation and flexion-supination, with hyperpronation boasting better success rates. Plus, find out what to do if reduction isn't effective. It's a valuable listen for anyone curious about pediatric emergencies and quick treatments!

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ANECDOTE

Classic Presentation In Toddlers

Aaron Lessen describes a typical nursemaid's elbow scenario in toddlers after being pulled by the arm.
The child cries, holds the arm close to the body, and often has no other trauma signs.

INSIGHT

X-Rays Usually Unnecessary

Nursemaid's elbow (radial head subluxation) usually doesn't require x-rays and often looks normal.
Aaron Lessen notes that manipulation during x-ray prep can itself reduce the injury.

ADVICE

How To Reduce The Subluxation

Use classic maneuvers to reduce radial head subluxation: supination plus elbow flexion or hyperpronation.
Start with the arm extended and manipulate per technique until you feel a click or see improvement.

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Contributor: Aaron Lessen, MD

Educational Pearls:

What is a Nursemaid's Elbow?

A condition in which an elbow gets partially pulled out of place (a radial head subluxation)
Usually happens in kids under 5 because the ligaments around their elbow are still loose.
A common situation is when an adult pulls a child up by the hand or swings them by the arms. The sudden tug causes the radius to slip out of its normal spot at the elbow joint.

How are they identified?

These don't normally need an xray
The child will often hold their arm close to their side and refuse to use it
There's usually no swelling or obvious deformity.

Treatment?

Reduce the radial head subluxation. There are two possible techniques:
- Flexion and supination.
  - Start with the arm extended and pronated. Then supinate the forearm. Then bend the elbow up all the way.
- Hyper-pronation.
  - One hand stabilizes just above the child's elbow, the other holds the wrist. Start with the arm extended. Hyperpronate the forearm. Listen/feel for a click
The child is normally back to normal quickly, if not get the xray

Which is better?

Hyperpronation (Aksel, 2025)
- 10% first attempt failure rate
- Flexion-pronation has a 25% first attempt failure rate

References

Aksel G, Küka B, İslam MM, Demirkapı F, Öztürk İ, İşlek OM, Ademoğlu E, Eroğlu SE, Satıcı MO, Özdemir S. Comparison of supination/flexion maneuver to hyperpronation maneuver in the reduction of radial head subluxations: A randomized clinical trial. Am J Emerg Med. 2025 Feb;88:29-33. doi: 10.1016/j.ajem.2024.11.026. Epub 2024 Nov 18. PMID: 39579408.
Ulici A, Herdea A, Carp M, Nahoi CA, Tevanov I. Nursemaid's Elbow - Supination-flexion Technique Versus Hyperpronation/forced Pronation: Randomized Clinical Study. Indian J Orthop. 2019 Jan-Feb;53(1):117-121. doi: 10.4103/ortho.IJOrtho_442_17. PMID: 30905991; PMCID: PMC6394198.

Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4

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