The treatment of pulled elbow: a prospective randomized study. 

Taha AM. Arch Orthop Trauma Surg 2000;120(5-6):336-7

To evaluate the effectiveness in decreasing recurrence of cast application after manual reduction of pulled elbow. Sixty-four children with pulled elbow were randomized into two treatment groups: Group A underwent manipulative reduction followed by splinting the elbow in a flexed and supinated position for 2 days; group B underwent manipulative reduction only. Both groups were examined 2, 5, and 10 days later. None of the 33 patients in group A had a pulled elbow at follow-up. Four (13%) of 31 patients in group B had a pulled elbow 2-5 days later. Immobilizing the elbow for 2 days after manipulative reduction improves the success of treatment of a pulled elbow.

A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. 

Macias CG, Bothner J, Wiebe R. Pediatrics 1998 Jul;102(1):e10

OBJECTIVE: To compare supination at the wrist followed by flexion at the elbow (the traditional reduction technique) to hyperpronation at the wrist in the reduction of radial head subluxations (nursemaid’s elbow). MATERIALS AND METHODS: This prospective, randomized study involved a consecutive sampling of children younger than 6 years of age who presented to one of two urban pediatric emergency departments and two suburban pediatric ambulatory care centers with a clinical diagnosis of radial head subluxation. Patients were randomized to undergo reduction by one of the two methods and were followed every 5 minutes for return of elbow function. The initial procedure was repeated if baseline functioning did not return 15 minutes after the initial reduction attempt. Failure of that technique 30 minutes after the initial reduction attempt resulted in a cross-over to the alternate method of reduction. The alternate procedure was repeated if baseline functioning did not return 15 minutes after the alternate procedure was attempted. If the patient failed both techniques, radiography of the elbow was performed. RESULTS: A total of 90 patients were enrolled in the study. Five patients were removed from further analysis secondary to a final diagnosis of fracture, 84 were reduced successfully, and 1 failed both techniques. Demographic characteristics of each group were similar. Thirty-nine of 41 patients (95%) randomized to hyper-pronation were reduced successfully on the first attempt versus 34 of 44 patients (77%) randomized to supination. Two patients in the hyperpronation group required two attempts versus 10 patients in the supination group. Hyperpronation was more successful; 40 of 41 patients (97.5%) in the hyperpronation group were reduced successfully versus 38 of 44 patients (86%) in the supination group. Of the 6 patients who crossed over from supination to hyperpronation, 5 were reduced on the first attempt and 1 was reduced on the second attempt. CONCLUSIONS: In the reduction of radial head subluxations, the hyperpronation technique required fewer attempts at reduction compared with supination, was successful more often than supination, and was often successful when supination failed.

Ultrasonography of pulled elbow.

Kosuwon W, Mahaisavariya B, Saengnipanthkul S, Laupattarakasem W, Jirawipoolwon P. J Bone Joint Surg Br 1993 May;75(3):421-2

We used ultrasonography in ten children with pulled elbow to compare measurements of the radiocapitellar distance (RCD) on the affected and the unaffected sides. Similar measurements were made in a group of ten age-matched normal children. The mean RCD in pronation of the affected and normal sides in the patients with pulled elbows was 7.2 mm +/- 0.7 and 3.8 mm +/- 0.5, respectively (p < 0.0001). In the normal children the mean RCD in pronation was 4.5 mm +/- 0.5. We conclude that ultrasonography is of value for documenting pulled elbow in children.

Did you check your nursemaid’s elbow?

Kunkler CE. Orthop Nurs 2000 Jul-Aug;19(4):49-52; quiz 53-5

Imagine a parent innocently swinging around a toddler … a yank on an outstretched arm to keep a preschooler from falling … a caregiver attempting to move a reluctant child by dragging the child by the hand … a helping hand to lift a young child up over the curb or a high step. None of these activities is ever intended to hurt a child, yet the result of these specific activities send many children with anxious parents and caregivers to emergency departments and unscheduled pediatrician appointments each year. Nursemaid’s elbow, also known as a pulled elbow or a subluxated radial head, may result from the specific activities described above and is the most common dislocation injury handled by pediatricians. Most commonly occurring in the 1-year to 4-year old age group, nursemaid’s elbow is easily treated and generally has no long-term sequelae.

The epidemiology of radial head subluxation (‘pulled elbow’) in the Aberdeen city area.

Jongschaap HC, Youngson GG, Beattie TF. Health Bull (Edinb) 1990 Mar;48(2):58-61

The incidence of Radial Head Subluxation in young children in the Aberdeen City Area was ascertained by retrospective review to be 1.2% per year. One hundred and sixty-two cases were recorded, in children aged between 5 and 66 months. The epidemiological features of the condition are reviewed. Extrapolation of these figures to the population of England, Scotland and Wales would suggest an annual incidence of 50,000 cases. This is a condition treatable in general practice, provided of course that the patient is not taken direct to an Accident and Emergency Department.