pulled or lifted by that same arm Frequently, however, the history is of a fall or, in infants, that the arm was trapped beneath the torso as the child is rolled over Palpation of the elbow may elicit minimal or no pain at the radial head, but attempted supination, pronation, and elbow flexion usually elicits more discomfort Radiographs are not routinely recommended when the history and clinical presentation are classic, as the normal and affected elbows are usually indistinguishable radiographically Imaging should be obtained if the examination or history is atypical, or routine methods of reduction not succeed The two most commonly used reduction techniques are supination and flexion at the elbow, or hyperpronation with an extended forearm (see Chapters 38 Immobile Arm and 130 Procedures, section on Reduction of Nursemaid’s Elbow ) There are some data suggesting that the pronation approach may be more effective on first attempt and less painful When reduction succeeds, the child typically uses the arm normally within to 10 minutes There is no need for immobilization after first subluxation With recurrent subluxations, immobilization for a few weeks in a posterior splint with the elbow at 90 degrees and with the forearm supinated may be considered Note that even when efforts at closed reduction fail, spontaneous reduction almost invariably occurs Once alternative diagnoses have been excluded, persistently symptomatic patients with a suspected nonreduced radial head subluxation may be discharged in a sling or posterior splint with orthopedic follow-up Injuries of the Forearm Fractures of the Radial and Ulnar Shafts Goals of Treatment ED management should include pain control and immobilization with the arm in a position of comfort, until definitive orthopedic reduction can be achieved CLINICAL PEARLS AND PITFALLS