Nursemaid's elbow and common upper-limb injury — formative SAQs

SAQ 1 (10 marks) — The two-year-old carried in refusing to use the right arm

Stem: A two-year-old girl is carried into the emergency department forty minutes after her father lifted her by the right wrist to swing her over a gutter. She cried briefly and has since refused to use the arm. She is afebrile, alert, and smiling, holding the right arm at her side with the elbow flexed to twenty degrees and the forearm pronated. There is no swelling, no deformity, no warmth, and no point tenderness, but she resists supination. Outline your assessment, your immediate management, and your discharge counselling. [1] [4]

Model answer

Assessment and diagnosis (3 marks). This is the classic presentation of a radial head subluxation (nursemaid's elbow). The decisive features are the classic mechanism — a sudden longitudinal pull on the pronated, extended forearm — and the well child holding the arm flexed and pronated with no swelling, no deformity, and no point tenderness. The diagnosis is clinical, and no radiograph is required in this classic case. The child is otherwise well, which argues against infection, and the absence of swelling and tenderness argues against a fracture. [4]

Immediate management — the reduction (5 marks). The reduction is attempted at the bedside by hyperpronation, the preferred first technique. The examiner holds the elbow with one hand, grasps the wrist with the other, and fully pronates the extended forearm in one smooth, firm, continuous motion, carrying the wrist into hyperpronation. The rationale is the randomised evidence: the Macias 1998 trial showed the first-attempt success of ninety-five per cent for the hyperpronation versus seventy-seven per cent for the supination-flexion, and the Aksel 2025 trial confirmed the lower first-attempt failure rate. The proof of success is the return of the normal arm use within fifteen to thirty minutes. If the child does not use the arm by thirty minutes, the hyperpronation is repeated once, then the supination-flexion (supinate the forearm and fully flex the elbow with a thumb over the radial head) is the cross-over. A radiograph is obtained only if both techniques fail or the history is atypical. [1] [6]

Discharge counselling (2 marks). The family is counselled that the annular ligament slipped over the radial head, that the reduction has restored it, and that the condition is benign. The single most important advice is to avoid longitudinal traction on the arm: lift the child under the axillae, do not swing the child by the arms, and hold the hand rather than the wrist when walking. Roughly a quarter to a third of children recur until the annular ligament matures around age five, and the family may be taught the hyperpronation technique to manage a recurrence at home. No follow-up or imaging is needed if the arm returns to normal use. [4]