summary Nursemaid's Elbow is a common injury of early childhood that results in subluxation of the annular ligament due to a sudden longitudinal traction applied to the hand. Diagnosis can be made clinically with a child that holds the elbow in slight flexion with pain and tenderness localized to the lateral aspect of the elbow. Treatment is usually closed reduction with either a supination or a hyperpronation technique. Epidemiology Incidence common Demographics most common in children from 1 to 4 years of age average age is 28 months rare after 5 years of age slightly more common in females Etiology Pathophysiology mechanism of injury sudden, longitudinal traction applied to the hand with the elbow extended and forearm pronated may also be caused by a fall pathoanatomy annular ligament becomes interposed between radial head and capitellum in children 5 years of age or older, subluxation is prevented by a thicker and stronger distal attachment of the annular ligament Presentation History a click may be heard or felt by the person pulling the child's arm Symptoms child refuses to use the affected limb holds the elbow in slight flexion and the forearm pronated Physical Exam pain and tenderness localized to the lateral aspect of the elbow range of motion full flexion and extension pain with supination Imaging Radiographs not required in the setting of the classic presentation of history of traction injury child five years or younger consistent clinical exam when obtained, elbow radiographs are normal 25% will show radiocapitellar line slightly lateral to center of capitellum Ultrasound indications helpful for confirming the diagnosis when necessary when the mechanism of injury is not evident when physical examination is inconclusive benefits no radiation to the patient can visualize soft tissues findings increase echo-negative area between capitellum and radial head sensitivity 64.9% and specificity 100% Differential Nursemaid elbow is a diagnosis of exclusion Differential diagnosis of a painful elbow with limited supination traumatic causes supracondylar fracture, olecranon fracture, radial neck fracture, lateral condyle fracture contusion infection septic arthritis congenital radial head dislocation forearm synostosis Treatment Nonoperative closed reduction of annular ligament subluxation indications for majority of cases must be certain no fracture is present prior to any manipulation Operative open reduction rarely required indications for chronic, symptomatic subluxations that cannot be reduced Techniques Closed reduction of annular ligament subluxation supination technique while holding the arm supinated the elbow is then maximally flexed the physician’s thumb applies pressure over the radial head and a palpable click is often heard with reduction of the radial head hyperpronation technique involves hyperpronation of the forearm while in the flexed position followup child should begin to use the arm within minutes after reduction immobilization is unnecessary after first episode Complications Recurrence may occur, especially if the child is younger than 3 years initially treat with cast application in flexion and neutral or supination Prognosis Excellent when reduced in a timely manner