About Nursemaid's Elbow

As parents, sometimes it's easy to forget that active preschoolers — who run, climb, jump and quickly hop up after falling — aren't as rough and tumble as their older siblings.

Kids this age are prone to nursemaid's elbow, a partially dislocated elbow joint. The medical term for this is called a "radial head subluxation."

Nursemaid's elbow, also known as pulled elbow, is a common mishap of early childhood. In fact it is one of the most common elbow injuries in kids. Kids 1 to 4 years years old are most commonly affected, though infants and older kids can experience it, too.

The injury happens in younger kids because their ligaments (the elastic-like bands that hold bones together) are loose and bones are not yet fully formed. This makes it easier for some of the bones to slip in and out of place.

As kids get older, however, their ligaments tighten and become thicker, bones enlarge and harden, and the risk of nursemaid's elbow decreases.

While a child with nursemaid's elbow has some initial pain in the arm, the injury does not cause any long-term damage. At the doctor's office, or in the emergency room, a medical professional can slip the bone back into place (usually without the need of any pain medications), causing symptoms to go away quickly.

Causes

The elbow joint connects the upper arm bone (humerus) to the lower arm bones (radius and ulna). The rounded tip of the radius (the radial head) is surrounded by a ligament (the annular ligament), that is sometimes loose in younger kids.

If not tight enough, the ligament may slip over the radial head and even tear. This causes the tip of the bone to move out of place, or subluxate. In some kids, this can happen very easily with just a small amount of force.

Other actions can increase the risk of injury, such as:

• Pulling a child up by the hands. Pulling on hands or forearms can put stress on the elbows. Never pick up a toddler or infant by the hands or wrists. Lifting under the armpits is the safest way to lift a child.
• Swinging a toddler by the arms. Any type of swinging by holding the hands or wrists can put stress on the elbow joint and should be avoided.
• Jerking a child's arm. Pulling a toddler along while walking or quickly grabbing his or her hand can jerk the arm, causing the radial head to slip. Remember to be gentle when taking a child by the hand.
• Breaking a fall with the arm. The natural response to falling is outstretching an arm for protection. The elbow can overextend during this action, resulting in a slip of the radial head.
• Rolling over in an awkward way. Sometimes rolling over in a crib, bed, or on the floor can cause nursemaid's elbow in infants and very young children.

Signs and Symptoms

Here's what to look for:

• The child refuses to use an arm. A child will not be able to use the injured arm without pain. Therefore, the arm is usually kept in a fixed, straight position to his or her side, or with a slight bend in the elbow. While the arm is kept in this fixed position, the child seems to have only mild pain or discomfort.
• No swelling or deformity. A child with nursemaid's elbow will probably not look injured because the subluxation does not cause the arm to have an obvious deformity or swelling at the elbow.

If injury to the arm or elbow is causing pain, this may be a sign of a fracture or contusion (bruise) to the bone. Nursemaid's elbow doesn't usually cause a child to have much pain. It can be difficult for the parent to tell the difference between a nursemaid’s elbow and a fracture, and that's why a doctor needs to check it out.

Contact your doctor if you suspect your child may have nursemaid's elbow. Do not try to put the bone back into place yourself.

Occasionally, the bone will move back into place on its own, such as after your child does something that moves the joint, like putting on a coat. Even if you think the bone has moved back into place, it's still important to visit the doctor to make sure that there's nothing else wrong with the arm.

Treatment

Your doctor may be able to treat a nursemaid's elbow injury or might refer you to the emergency room for treatment.

The doctor will first determine whether your child is likely to have nursemaid's elbow, based on the cause of injury and the physical exam. The arm, hand, and shoulder will be felt to make sure there's no swelling, tenderness, or other abnormality, which could point to a fracture instead.

X-rays are not needed to diagnose nursemaid’s elbow and are only done if a fracture is suspected. If there's no obvious swelling or other injury, the doctor will perform a gentle maneuver that allows the bone to go back into its normal place. The medical term for this is a reduction.

This procedure is very quick and takes only a few seconds. A child is usually asked to sit on a parent's lap while the doctor attempts to reduce the subluxation of the bone. During the procedure, the arm is taken from a straight position and bent upwards in a swift motion. The doctor will listen for a "pop" sound, indicating the bone is back in place.

The child may experience a moment of pain during the reduction, but soon after treatment the discomfort is gone. Most kids have full use of the arm within 5 to 10 minutes. Some cases may require more than one try to successfully reduce the elbow.

Occasionally, a child may avoid using the arm after the reduction for a brief time, fearing it will be painful. If discomfort continues, the doctor may put the arm in a sling and recommend acetaminophen or ibuprofen for pain relief.

Prevention

It's important to remember that sometimes nursemaid's elbow cannot be avoided. Some kids are just more prone to the injury than others. And those who get nursemaid's elbow may get it again.

So be mindful of the risks and, whenever possible, avoid tugging, swinging, or jerking on your child's hands or arms, and be sure to tell caregivers to do the same.

Reviewed by: Yamini Durani, MD
Date reviewed: April 2011