Nursemaid’s Elbow

Here’s a scenario for you: You’re holding your toddler’s hand while walking at the park. You tell your toddler it’s time to go. She decides this does not jive with her plans, so she lets her legs go loose. Like the good parent you are, you hold on to that “sweet” hand so she doesn’t bust her head on the ground, just to hear an ear-piercing scream from your child. You let go, and realize she is holding her arm on her belly, and refusing to move it. Great. You’ve just given yourself the “World’s Best Parent” award for breaking your child’s arm…so you go straight to KidMed.

 

This scenario (or one similar to it) is SUPER COMMON. When I see a toddler or preschool-aged patient with “elbow injury” or “arm injury” show up on my screen, it is almost always a nursemaid’s elbow, and not a broken arm. Let me elaborate.

 

Kids are pretty bendy. They have to be. They’re growing really quickly, so stuff tends to be stretchier and softer to accommodate the rapid growth rate. So, when there is some kind of pulling or twisting injury of a stretchy elbow, it makes sense that a dislocation would happen. And that, my friends, is exactly what a nursemaid’s elbow is: a dislocation. Not a fracture. Pulling and twisting injuries are the most common causes. But sometimes, a fall onto the elbow, or rolling over on the elbow (for younger infants) can be enough to knock stuff out of place. Around age 5, the ligament involved gets less stretchy, so a nursemaid’s elbow is fairly uncommon (but still possible!) in kids 5 and older.

 

The annular ligament holds the lower arm bones together at the elbow. Stretching a toddler’s or preschooler’s arm allows that annular ligament to slip into the elbow joint and get stuck. The radius (one of the lower arm bones) can then shift. The ends of the radius and ulna at the elbow are like the end of two pencils wrapped together by a rubber band. When the arm gets pulled or twisted, the end of one of the pencils (the head of the radius) slips out from under the rubber band. Kids will typically hold their forearm flexed and braced against their bellies, or keep their arm extended and limp by their sides. These kids will not use the injured arm. It hurts. But, if the arm is still, they’re usually pretty comfortable.

 

The arm itself looks pretty normal; no deformity, bruising, swelling, etc. Kids may complain of generalized arm pain, and some kids may have local tenderness right on the elbow. They may even allow the provider to move the injured arm and elbow. The pain comes, though, when I try to pronate the forearm. By this I mean, rotate the forearm so the palm is facing the ground. This twisting motion hurts because it’s putting direct pressure on the dislocated bone and trapped ligament.

 

A nursemaid’s elbow is a clinical diagnosis.

 

This means I do not need to x-ray the child’s arm when there is high suspicion for a nursemaid’s elbow and low suspicion for a fracture. Yay for avoiding radiation! However, if the exam doesn’t look right, or the story doesn’t make sense, I do order x-rays for these kids. I would much rather be certain that nothing is broken before I go twisting these arms, possibly making things worse.

 

So that brings me to how I fix a nursemaid’s elbow.

 

It’s really very simple. I either give your child a handshake and flex her forearm to her shoulder, or I gently rotate her palm towards the floor. Usually, I can feel the click of the ligament and radius going back where they belong. When we reduce the nursemaid’s elbow, we are simply getting the end of that bone back under the rubber band (ligament). The plucking of that ligament is the “click” that we feel for. Some kids actually “reduce” a nursemaid’s elbow on their own just by using it, or it may even reduce when positioning an arm for an x-ray.

 

There is immediate pain relief once everything is in its place. Some kids use the injured arm without trouble right away, but others are a little more hesitant. Nearly every kid uses the affected arm to reach for a popsicle, though. And that is the “test of cure,” so to speak. When your child uses her limp and injured arm without any pain or hesitance, the visit is over.

 

Once the nursemaid’s elbow is reduced, the elbow is essentially back to normal. As if the injury never happened.  An episode of nursemaid’s elbow does not typically increase the risk of it happening again.

 

Occasionally, an elbow doesn’t reduce, and a kid still has pain. In this case, x-rays are warranted. Kids with a fracture are splinted and go see an orthopedist; kids without a fracture get a sling, some ibuprofen and ice, and a follow-up with their pediatrician in 2-3 days.

 

To prevent nursemaid’s elbow, don’t pull hard on your child’s arm or lift her up by the hand, wrist, or forearm. But, if life happens, the pediatric experts at KidMed are here to help!

 

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