A hyperpronation or a supination-flexion technique may be used to reduce a radial head subluxation (nursemaid’s elbow). These techniques are safe and require no special equipment, assistants, analgesia/sedation, or post-procedure immobilization.
- Radial head subluxation
- Distal neurovascular compromise, which indicates a more severe injury than radial head subluxation
- Physical signs of injury (deformity, swelling, bruising, pain, and tenderness) beyond the radial head area, unless findings are mild and significant injury has been ruled out
- Evidence of infection
- Further damage, if the injury is more extensive than radial head subluxation and is not recognized
- Pre-procedure x-rays are not needed if clinical evaluation indicates a simple radial head subluxation. However, if there are physical signs (deformity, swelling, bruising, pain, tenderness) of other, concurrent injuries, a pre-procedure x-ray of the suspect area is required.
- The hyperpronation technique may cause less pain than the supination-flexion technique and may also have a higher rate of successful reduction.
- The annular ligament wraps around the radius and attaches at both ends to the ulna and thus holds the radius in place against the ulna at the radioulnar joint.
- The radial head can be palpated superficially at its articulation with the lateral humeral epicondyle. Unlike the epicondyle, the radial head rotates when the wrist is pronated or supinated.
- Position the child next to the caregiver or on the caregiver’s lap, with the caregiver holding the child’s torso and unaffected arm.
Step-by-Step Description of Procedure
- Do a pre-procedure examination of the affected arm: Neurovascular examination includes assessing distal pulses and capillary refill. Palpation of surrounding areas for tenderness may suggest additional injury.
- Face the child and hold the affected elbow in the palm of one hand, placing your thumb over the radial head.
- Hold the wrist in your other hand, with your thumb and fingers on opposite sides of the wrist.
- Explain to the caregiver that the technique will cause transient pain.
- Maintain the elbow at 90° of flexion.
- For the hyperpronation technique, rapidly hyperpronate the forearm. Some experts recommend further flexion of the elbow immediately after hyperpronation.
- For the supination-flexion technique, using one continuous motion, rapidly and firmly supinate the forearm, then fully flex the elbow.
- Listen for a click or a palpable pop at the radial head, which may accompany a successful reduction.
- The child may cry for a few minutes after successful reduction; analgesia is unnecessary.
- Leave the room to allow the child time to start using the arm. Nearly all children will start using the arm spontaneously or in response to an offered toy or snack within 30 minutes.
If the child does not move the arm after 30 minutes, formulate a care plan in concert with the parents, choosing among options such as
- Attempting reduction a second time
- Discharging patient and the family to home, with instructions to return (or see the family doctor) if the child is not using the arm fully upon arrival
- Obtaining an x-ray of the elbow prior to discharge
Note the following:
- Immobilization is not required after successful reduction.
- Instruct caregivers to use the axilla when picking up the child.
Tips and Tricks
- Placing the thumb over the radial head may facilitate recognition of a successful reduction via the palpable click or pop. When the supination reduction method is used, some experts recommend pressing on the radial head, with or without simultaneously pronating and supinating the wrist, during forearm flexion.