Nursemaid's Elbow in Children

While nursemaid elbow is usually a temporary condition without permanent consequences, it can be quite frightening to parents who find their child suddenly lacking the ability to use his or her arm.

Nursemaid elbow is a common injury among preschool-aged children. Nursemaid elbow refers to a condition (medically called radial head subluxation) in which the normal anatomical alignment of two of the three bones that form the elbow joint is disrupted. Girls are more commonly affected than boys; the left arm is more often injured than the right. Nursemaid elbow is thought to be secondary to the likelihood of the parent being right-handed (and thus most frequently pulling their child's left hand). The injury can occur innocently from swinging a young child by the arms or pulling a child's arm while in a hurry. It takes relatively little force to pull the bones of a young child's elbow out of place.

• Commonly called dislocated elbow
• While nursemaid elbow is usually a temporary condition without permanent consequences, it can be quite frightening to parents who find their child suddenly lacking the ability to use his or her arm.
• The elbow joint involves the two bones of the forearm (radius and ulna) and the bone of the upper arm (humerus, hence the name "funny bone"). The ulna is the bone that is on the side of the forearm that has the baby's finger. The radius runs the length of the forearm on the thumb side. The radius forms an individual connection with the capitellum, the far end of the humerus. The relationship between the ulna and the humerus is sturdy. However, the head of the radius requires a tight ligament (the annular ligament) to anchor the radial head into the proper region of the capitellum. If the radial head receives a sudden pull or is subjected to chronic traction, this ligament may partially tear and slip out of position, allowing the radius to lose its proper fitting in the "socket" at the end of the humerus.
• Typically, this type of injury occurs in children 1-4 years of age but has occurred in infants 6-12 months of age as well. The peak incidence is 27 months of age. As children grow, their bones become larger and more defined. In addition, ligaments become stronger and thus provide a better support system. Nursemaid elbow is rarely seen in children older than 6 years of age unless the child is involved in prolonged hanging by the hands or prolonged lifting of heavy objects. (The appellation "nursemaid elbow" comes from a time when children of upper social class families commonly were cared for by a nursemaid or nanny.)

• Immediately after the injury occurs, the child generally cries in pain and will refuse to use the involved arm.
• Typically, the arm will be protected against the body and held slightly bent (in flexion) with the forearm turned with the thumb toward the body (in pronation).
• The child will often support the painful arm with their other hand.
• The child will usually be calm shortly after the initial event and may return to playing only now without the use of the affected arm.
• When the forearm is turned with the thumb away from the body to show the palm upward (in supination), the child will resist and cry in pain.
• A child who is old enough to talk may often describe pain in the wrist or shoulder in addition to, or in place of, any pain in the elbow.
• Most commonly, your child will appear completely unchanged with the exception that he or she will no longer use the injured arm.

Nursemaid elbow results from a sudden pulling force applied to the extended arm of a child. Due to the relative strength of the adult in comparison to the weakness of the child's supportive annular ligament, the applied force may not seem strong to the parents and they may not realize an injury has occurred.

Examples of typical situations that can produce the mechanism of force required to cause this injury are lifting the child up from the ground by the hand or wrist, swinging the child while holding the child by the hands or wrists, pulling arms through the sleeves of jackets, catching a child by the hand to prevent a fall, and pulling a child along when in a hurry or the child suddenly collapsing to the ground in an effort to avoid going with their parent.

The young child is prone to this type of injury largely because of the anatomical features of their bones and ligaments. Understanding the mechanism of this injury is helpful in explaining the cause.

• The end of the radius that connects to the elbow joint is known as the radial head. The radial head has a shallow concave shape allowing it to fit over a complementary convex prominence at the end of humerus (the capitellum). As the child matures, the radial head broadens and ultimately becomes wider than the portion of the radius (called the radial neck) adjacent to the head. In the young child, the radial head does not yet have a well-defined lip at its end. As such, in the toddler, the radial neck and radial head are similar in size.
• The annular ligament holds the radius alongside the ulna, which is the other bone in the forearm. Besides stabilizing the radial head-humerus joint, the annular ligament permits the radius to twist when the hand changes position from palm down (prone) to palm up (supine). In young childhood, the annular ligament is still relatively loosely attached to the bone and can experience a small tear in some of its fibers.
• The combination of these two things (shallow concave radial head and loose-fitting annular ligament which may easily partially tear) allows the loose portions of the ligament to slide over the radial head when a pulling force is applied to the elbow while the forearm is slightly rotated palm down (pronation). When this happens, this annular ligament tissue can become trapped between the radial head and the capitellum, resulting in the subluxation of the radial head, or nursemaid elbow.

The doctor will obtain the history of how the injury happened by asking what occurred just before the event or what activities were being performed. Additional history specifically about the use of the arm, positions in which the arm has been held, and anything that has made the condition worse or better is very important.

• The doctor will feel the arm and look for any evidence of other injuries. The doctor will be looking for tenderness over any portions of the bones being felt in the arm. There may be some slight tenderness over the radial head.
• X-rays are typically not obtained or required unless another condition, such as a fracture (broken bone), is suspected, or if the reduction attempts are not successful. Indications for possible fracture include significant swelling or bruising of the elbow area or a mechanism of injury not consistent with nursemaid elbow (for example, fall from a chair). X-rays appear normal in most children with radial head subluxation and thus are not helpful in diagnosis.

Call your doctor immediately after the injury. If your doctor feels comfortable seeing you in the office and can get you in right away, putting the bones back in place (this is called reduction) can be performed in the office very quickly. If you are unable to get an appointment or cannot be seen in the doctor's office for any other reason, go to the hospital's emergency department for evaluation and corrective actions. Any trauma other than a simple pulling on the hand or forearm might require further evaluation or X-rays done in the hospital. If you notice a deformity, large swelling, bruising, or anything else concerning to you, go to the emergency department for evaluation of your child.

The doctor will move the bones back into place (the subluxation will be reduced) in this manner:

• The child will sit on the parent or guardian's lap facing the doctor. While gently feeling the radial head with one hand, the doctor will hold the affected hand and turn it palm upward (causing supination) while fully bending (flexing) at the elbow. Alternatively, the forearm may be fully straightened with the palm inward (pronation). Often a click will be felt by the doctor and rarely may be heard.
• Your child will probably cry briefly during the procedure. After the reduction, movement will generally be pain free, and the child will quickly revert to using his or her arm as if nothing were ever wrong.
• If this procedure does not produce the expected results, it may be repeated using the same technique. After several attempts, if the child has not improved, X-rays may be ordered to check for bone fractures. There are many reports of relocating the radial head during the X-ray process due to positioning the elbow by the technologist.
• If the reduction is not possible in the emergency department, the child may have a temporary splint placed on the arm with close follow-up arranged. This situation may occur more often if the parent has delayed medical attention for the condition and the annular ligament is thus overly stretched. On follow-up examination, the elbow has often reduced itself spontaneously or will be more likely to succeed on reattempt. It is very rare to need an operation to restore the proper elbow anatomy.

Should initial reduction attempts be unsuccessful and a splint is required, follow-up should be done in 24-48 hours. If the child continues to have any loss of function of the affected arm, bruising, deformities, or other unexpected or unusual findings, a reevaluation is in order. Should the child experience this condition time after time, the doctor may put the arm in a cast to keep it immobile and discuss surgery to "tighten" the annular ligament.

• The application of a cool, moist towel or small bag of ice wrapped in a towel may be helpful in any type of acute injury.
• Acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) for pain can also be given.
• The most important action should be to seek appropriate medical attention.

Avoid any sudden jerking to the hand, wrist, or forearm of any small child to prevent this injury. This is even more important in the child who has already experienced a nursemaid elbow. Pick up the child by placing your hands on his or her chest and under the axillae.

The condition poses no long-term problems, but it can happen again easily.