Nursemaid's Elbow

Written by: Richmond Castillo, MD (NUEM ‘23) Edited by: Shawn Luo, MD (NUEM ‘22)
Expert Commentary by: Jacob Stelter, MD (NUEM ‘19)

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Expert Commentary

This is an excellent summary of the diagnosis and management of radial head subluxation (nursemaid’s elbow) in children.  Clinically, as pointed out, these patients are usually toddlers and will come in after an injury to the arm.  Usually, the clinical history will involve the child’s arm having been pulled on while the elbow was extended leading to sudden onset of pain and reduced mobility of the arm.  The patient will most often be holding the elbow in flexion and be resistant to having it manipulated.  In general, I have a low threshold to obtain radiographs on these patients.  If the story and exam is classic for a radial head subluxation, imaging is technically not indicated, and reduction can be attempted.  However, more often than not, the history can be vague, and the mechanism of injury may be unclear.    In this situation, it is better to rule out a fracture first than to attempt a reduction without imaging.  Attempted reduction could worsen or lead to displacement of a supracondylar humerus fracture if that is present.  Keep in mind that it is not uncommon for the subluxation to reduce spontaneously during the process of obtaining x-rays.  

There are two preferred techniques for reduction of a radial head subluxation.  The method I start with is to support the patient's elbow and forearm and gently supinate the forearm while flexing the elbow and applying gentle pressure over the radial head.  A “pop” sensation will often be felt as the radial head reduces.  The other technique that can be used is to hyper-pronate the forearm while maintaining the elbow in a flexed position.  Both of these techniques have a high success rate.  Typically, the child will start using the arm again, but it may not be immediate.  I will typically reassess the patient about 10-15 minutes post-reduction to ensure they are using their arm normally again.  If the child is using their arm and able to extend and flex at the elbow without pain, they can be discharged, and no splinting is necessary.  If no radiographs were obtained prior to reduction and the patient is not back to baseline post-reduction, x-rays should be obtained to rule out a fracture. Keep a broad differential, especially if the patient is not responding as you would expect or has other vital sign or exam abnormalities.

Jacob Stelter, MD, CAQ-SM

Division of Emergency Medicine | NorthShore University HealthSystem

NorthShore Orthopaedic Institute | Primary Care Sports Medicine

Clinical Assistant Professor | University of Chicago Pritzker School of Medicine

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Castillo, R. Luo, F. (2022, Feb 7). Nursemaid’s Elbow. [NUEM Blog. Expert Commentary by Stelter, J]. Retrieved from http://www.nuemblog.com/blog/nursemaids-elbow.

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Temporomandibular Joint Reductions

Written by: Trish O’Connell, MD (PGY-2)  Edited by: Jacob Stelter, MD (PGY-3)  Expert commentary by: Matt Levine, MD

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Expert Commentary

That was a high yield visual guide to TMJ reductions.  Earlier in my career I was often frustrated by these cases.  I was taught the traditional reduction method. I found myself having to sedate the patient and stand on the bed to generate enough downward force.  This was awkward and I was still usually unsuccessful. The wrist pivot method really changed my practice. I found it required less sedation, easier to generate force without awkward positioning, required less physical strength, and led to higher success rates for me.  My current practice is to have a patient roll a 10mL syringe in their mouth while I am setting up, which usually doesn’t work, and to proceed with the wrist pivot technique if still dislocated.  

While procedural sedation has evolved away from versed and more towards agents such as ketamine, etomidate, and propofol, versed remains an ideal agent for TMJ reduction.  It provides good anxiolysis and is a better muscle relaxant than etomidate and ketamine.  The deep sedation of propofol is unnecessary.

When the sedated patient awakens, beware of “the yawn”!  I’ve had patients dislocate again that way, to the chagrin of the patient (and the benefit of the procedure-seeking resident).  Wrapping Kerlex gauze under the chin and around the top of the head until the patient is alert enough to avoid full yawning will prevent “the yawn.”

The main role of imaging is to rule out associated fracture.  Plain films are generally inadequate to confirm or rule out TMJ dislocation.  If you really need imaging, CT is the best test. If the patient had no trauma but their mouth is stuck open, you usually won’t need imaging.

Matthew R. Levine, MD

Assistant Professor

Department of Emergency Medicine

Northwestern University

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How to Cite this Post

[Peer-Reviewed, Web Publication] O’Connell, T, Stelter, J. (2020, Mar 2). Temporomandibular Joint Reductions. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from https://www.nuemblog.com/blog/tmj-reduction

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