Paeds · rheumatology-musculoskeletal-and-sports
Nursemaid's elbow and common upper-limb injury
Also known as nursemaid's elbow · pulled elbow · radial head subluxation · annular ligament displacement · hyperpronation reduction · supination-flexion reduction · supracondylar humerus fracture · Gartland classification · torus fracture · buckle fracture · greenstick fracture · clavicle fracture · lateral pinning
A fellowship approach to nursemaid's elbow (radial head subluxation) and the common paediatric upper-limb injuries: the classic traction history and the well child holding the arm in flexion and pronation, the two reduction manoeuvres with hyperpronation as the preferred first technique over supination-flexion on the evidence of the Macias and Aksel randomised trials, the dispensable role of radiographs in the classic case, the counselling to prevent recurrence, and the broader family of common upper-limb injuries — the supracondylar humerus fracture read through the Gartland classification with the lateral-entry pinning and the volar pulseless hand, the torus and the greenstick forearm fractures with the remodelling principle and the FORCE soft-bandage evidence, and the clavicle fracture of birth and fall.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- A well-looking child under five who holds the arm flexed and pronated after a pulling injury has a radial head subluxation until proven otherwise, and the reduction is attempted before any radiograph
- A child whose radial head subluxation does not reduce after both techniques, or whose history is atypical, must have a radiograph, because a missed lateral condyle or supracondylar fracture hides among the pseudoparalysed arms
- The pulseless, cold, or profoundly pale hand after a supracondylar fracture is a vascular emergency: the elbow is reduced and pinned in theatre and the vascular surgeon is involved without delay
- The non-mobile infant with a clavicle or long-bone fracture, or a fracture that does not fit the offered mechanism, enters the safeguarding pathway, because inflicted injury is excluded by the workup and not by the assumption
- A torus or buckle fracture of the distal radius is overtreated if splinted in a rigid cast for weeks — the FORCE trial showed a soft bandage to be no worse and better tolerated
Life stages
Care settings
Clinical exam formats
Board mappings
- Musculoskeletal medicine - recognise nursemaid's elbow and the common upper-limb injuries of childhood
- Acute presentations - the child who will not use the arm and the application of the reduction manoeuvre
- Orthopaedics and musculoskeletal medicine - the two reduction techniques and the evidence for hyperpronation as the first-line
- Acute and critical care - the Gartland classification and the vascular emergency of the pulseless supracondylar hand
- Musculoskeletal 10-12
- Acute presentations 10-12
- Short Cases
- Long Cases
- 9. Musculoskeletal medicine - upper-limb injury in children
- 1. Clinical assessment and the limping or guarding child
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline - D9 Orthopedics
- General Pediatrics Content Outline - Universal Task 3: Physical Examination and Universal Task 5: Patient Management
- Patient Care 5: Patient Management
- Medical Knowledge 2: Conditions common in pediatric primary care including nursemaid's elbow and upper-limb fractures
- Systems-Based Practice 2: Coordinated care with paediatric orthopaedics for the displaced fracture and the vascular emergency
- Medical Expert
- Pediatrics: Rheumatology and orthopaedics applied domain
A two-year-old girl is carried into the emergency department forty minutes after her father, hurrying across a carpark, lifted her by the right wrist to swing her over a gutter. She cried briefly, then 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 on palpation of the elbow, but she resists supination. The history is classic for a radial head subluxation. The reduction is attempted by hyperpronation: the examiner holds the elbow and fully pronates the extended forearm in one smooth motion. Two minutes later the child reaches for a toy with the right hand. The clinical skill is to recognise the pattern, reduce without a radiograph, and counsel the family. [1] [4]
Hold the two reduction manoeuvres by the evidence. Hyperpronation is the first technique you reach for: the elbow is held, the forearm is fully and firmly pronated, often with the wrist carried into hyperpronation in one continuous motion. The Macias 1998 and the Aksel 2025 randomised trials both showed a higher first-attempt success rate with hyperpronation than with supination-flexion, and the Aksel trial found a lower first-attempt failure rate. Supination-flexion is the alternative: the forearm is fully supinated and the elbow is then flexed fully, with the examiner's thumb pressing over the radial head. Both are safe; hyperpronation is preferred. The proof of reduction is the return of normal arm use within fifteen to thirty minutes, not the click. [1] [6]
Overview & Definition
Nursemaid's elbow, also called a pulled elbow or a radial head subluxation, is the displacement of the annular ligament onto or into the radiocapitellar joint that follows a sudden longitudinal traction force applied to the pronated and extended forearm of a young child. It is the commonest upper-limb injury of early childhood seen in primary care and in the emergency department, and it is the archetype of a benign, easily treatable condition whose recognition is entirely clinical. The child is well, the arm is guarded in flexion and pronation, and there is no swelling, no deformity, and no bony tenderness — features that, together with the classic pulling history, make the diagnosis without any imaging. [4] [5]
The clinical importance of nursemaid's elbow lies in the ease of the bedside cure and in the prevention of the recurrence. The reduction is a ten-second manoeuvre, performed in the consulting room or the emergency department, that restores the arm to full use within minutes; the radiograph is unnecessary in the classic case and is reserved for the atypical history or the failed reduction; and the counselling — the single most important element of the disposition — turns the family into the safeguard against recurrence, because the child who is pulled by the wrist or swung by the arms will subluxate again. Roughly a quarter to a third of children recur, and the recurrence is prevented by the simple avoidance of longitudinal traction, not by any immobilisation or restriction. [3] [4]
The page that follows treats nursemaid's elbow as the paediatric generalist encounters it: recognised on the history, reduced at the bedside, discharged with counselling, and prevented from recurring. It then widens to the broader family of the common upper-limb injuries that share the presentation of the guarding arm or the injured limb — the supracondylar humerus fracture, the torus and the greenstick forearm fractures, and the clavicle fracture — because the generalist's task at the bedside is to separate the easily reduced subluxation from the fractures that need splinting, orthopaedic referral, or the vascular check. [5] [7]
References11ShowHide
- [1]Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics, 1998.PMID 9651462
- [2]Macias CG, Wiebe R, Bothner J. History and radiographic findings associated with clinically suspected radial head subluxations. Pediatric Emergency Care, 2000.PMID 10698138
- [3]Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom-Smit LW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews, 2017.PMID 28753234
- [4]Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. American Journal of Diseases of Children, 1985.PMID 4061421
- [5]Schutzman SA, Teach S. Upper-extremity impairment in young children. Annals of Emergency Medicine, 1995.PMID 7574131
- [6]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. American Journal of Emergency Medicine, 2025.PMID 39579408
- [7]Abzug JM, Herman MJ Management of supracondylar humerus fractures in children: current concepts. Journal of the American Academy of Orthopaedic Surgeons, 2012.PMID 22302444
- [8]Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. Journal of Bone and Joint Surgery. American Volume, 2001.PMID 11379744
- [9]Perry DC, Achten J, Knight R, et al. Offer of a bandage versus rigid immobilisation in 4- to 15-year-olds with distal radius torus fractures: the FORCE equivalence RCT. Health Technology Assessment, 2022.PMID 35904496
- [10]Zorrilla S de Neira J, Prada-Cañizares A, Marti-Ciruelos R, et al. Supracondylar humeral fractures in children: current concepts for management and prognosis. International Orthopaedics, 2015.PMID 26311512
- [11]Heyworth BE, Pennock AT, Li Y, et al. Two-Year Functional Outcomes of Operative vs Nonoperative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results From the Prospective Multicenter FACTS Study Group. American Journal of Sports Medicine, 2022.PMID 35984091