Nursemaid's Elbow With Transient Wrist Drop in a Toddler: An Atypical Presentation

Radial head subluxation, commonly known as nursemaid's elbow, is a frequent upper extremity injury in young children and typically presents with refusal to use the affected arm without focal distal motor dysfunction. We report an atypical presentation in a previously healthy two-year-and-10-month-old girl who was brought to the emergency department after an unwitnessed event with no clearly identified mechanism of trauma. She held her right elbow flexed against her chest in a posture suggestive of radial head subluxation, and additionally refused to let go of her wrist and demonstrated a wrist-drop posture, absence of active finger movement, mild wrist edema, and tenderness predominantly over the wrist. An initial reduction using a hyperpronation maneuver produced no palpable or audible click and no clinical improvement. Because of the atypical distal findings, further manipulation was deferred, and radiographs of the affected extremity were obtained, showing no acute fracture or dislocation. A second hyperpronation reduction was subsequently performed, during which a distinct palpable and audible click was appreciated. Immediately afterward, active wrist extension returned and the wrist-drop posture resolved. The patient reached for and successfully held an object, and within approximately two minutes demonstrated full spontaneous movement of the affected upper extremity without residual tenderness, edema, or apparent motor deficit. She was observed for 20-30 minutes and subsequently discharged home. This case highlights an unusual neurologic-appearing presentation of radial head subluxation. The rapid resolution following successful reduction suggests a close association between the subluxation and transient distal dysfunction; however, pain-mediated pseudoparalysis and transient radial motor nerve dysfunction cannot be reliably distinguished in a young child.