It’s another busy afternoon in the peds ED when grandma comes in stating that her grandson broke his arm. He was jumping on the bed, and reached out to grab hold of a side rail before falling to the ground. It looks normal, but now the little guy refuses to use the arm and is reluctant to be examined. You suspect a nursemaid’s elbow.

Nursemaid’s elbow occurs in children when there is longitudinal traction placed on the extended arm resulting in subluxation of the radial head.  The annular ligament is partially torn or caught between the radial head and capitellum causing pain when ranging the joint.The typical story is when a parent abruptly pulls while holding the hand of a child.

You are about to perform the traditional supination-flexion maneuver when your attending asks if you’ve considered an alternative method.

Hyperpronation is the alternative method with several studies supporting higher success rates with this technique. For this maneuver, the patients elbow is at 90 degrees flexion and the clinician holds the wrist and rotates the forearm until it is hyperpronated. A palpable click is usually felt once reduced.

You successfully reduce the patients elbow on the first attempt and he immediately resumes normal use of the arm. There is no need for immobilization.

Here is a video that demonstrates both techniques: