Written by Clay Smith
Missed fractures are rare in children who are diagnosed with a nursemaid’s elbow. We can safely use x-ray in these children less often. There are some tips for you below.
Ilene Claudius teaches PEM like a pro
Why does this matter?
It seems almost reflexive to x-ray a child with a hurt arm. But is it necessary? Could we do this less often in select cases?
Come on, nursemaids…why so rough?
This was a retrospective review of 45 pediatric EDs over 9 years that identified 88,466 patients with a diagnosis of nursemaid’s elbow. Median age was 2.1 years, 59% female, 60% left arm. Missed fractures, defined as upper extremity fracture detected within 1 week of the original encounter, were extremely rare: 247 cases (0.3%). However, 28.5% of initial visits had an x-ray performed. This indicates that we could likely perform radiography less often. Children were more likely to have a missed fracture if they were older than 6 years, had an x-ray on the initial visit, or got ibuprofen or acetaminophen at the initial visit. Nursemaid’s occurred most often in children 1-3 years of age, 85.3% of cases.
Here is how I think about this. Are they a toddler? Careful if they’re older than 3-ish. Look at the mechanism: low or potentially higher energy? Look at how they hold their arm: classic palm down, tucked against their side? Calm the patient down – pacifier, Baby Shark (Noooo!), bottle, whatever – and carefully palpate for point tenderness while they are happy and distracted. Here is a little pearl. If no point tenderness, see what happens with slight supination of the wrist. This usually causes pain in a nursemaid’s. If a toddler has no point tenderness, no bruising or swelling, low energy mechanism, and is holding the arm adducted*/pronated – it is probably a nursemaid’s. Don’t x-ray them. To reduce, I recommend hyperpronation. It is so much better than supination/flexion. This is not just borne out in the literature, although that is true. As I have changed my practice, I have done a dozen or so of these with 100% success using hyperpronation. But take that anecdote for what it’s worth…
* Post corrected from abducted to adducted. Sorry about that typo.
Management and Outcomes of Children With Nursemaid’s Elbow. Ann Emerg Med. 2021 Feb;77(2):154-162. doi: 10.1016/j.annemergmed.2020.09.002. Epub 2020 Oct 27.