Nursemaid’s elbow: Its diagnostic clues and preferred means of reduction
This systematic review revealed that correcting the injury with pronation is more successful and less painful than supination.
Children are often referred for radiographic examination with the observation, “refuses to use arm; please x-ray from shoulder to wrist.”20 Radiography is of little help, however, and exposes the child to a dose of ionizing radiation. Although some studies show small significant differences between nursemaid’s elbow and the normal elbow,21-23 radiographic results generally are reported as normal.4,6,8,24 (Some commentators assume this may occur if the radiology technician repositions the arm in an attempt to obtain a true anteroposterior projection of the elbow.1,18,25) Restrict radiography, therefore, to cases with an unclear history or a history of trauma other than arm pull, to exclude more severe injuries.
The role of sonography is not yet clear, but it may turn out to be a fast and harmless technique for diagnosing uncertain cases.20,25,26
Treatment
Although no articles have described the natural course of nursemaid’s elbow, most authors report that it resolves on its own when a child moves the arm in supination or pronation. It is so easily treated that parents of children with recurrent episodes have even been instructed by phone how to perform the reduction.27
Most articles and textbooks recommend reducing nursemaid’s elbow by a rapid supination of the forearm, followed by flexion or extension.9,28 However, some articles have described a pronation method.29 We found 2 high-quality trials that compared the success rate of the supination method with the pronation method.30,31 Researchers conducting 1 medium-quality trial assessed the difference in pain experienced with these 2 methods.32 And researchers conducting 1 low-quality trial tried to assess whether splinting after manipulation helps to prevent recurrences of nursemaid’s elbow.10
These trials indicate the pronation method is more successful. In addition, some studies report that the pronation method is less painful for the child and less frightening for a parent to watch.29-31 Green et al confirmed this in their randomized trial.32
Most compelling finding
The highest quality studies were those devoted to treatment,28,30-33 and the clear conclusion from their findings—in contrast to what textbooks recommend—is that reduction with a pronation maneuver is more often successful than the supination method. Of course more studies will be needed before textbooks change their recommendations. But at least these studies provide helpful guidance now.
CORRESPONDENCE
Marjolein Krul, MD, Department of General Practice, Room Ff304, Erasmus MC-University Medical Center Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands; m.krul@erasmusmc.nl
