Orthopaedic Surgery - Nursemaid’s Elbow

Basics

Nursemaid’s elbow is a common injury of early childhood involving the annular ligament around the radial head.

It occurs when longitudinal traction on the arm causes the annular ligament to become displaced or entrapped between the radial head and capitellum.

The child typically responds by:

Guarding the arm

Refusing to use the elbow

Holding the affected upper extremity close to the body

The injury is commonly referred to as a radial head subluxation, although the underlying abnormality primarily involves displacement of the annular ligament rather than a true complete dislocation of the radial head.

Synonyms

Nursemaid’s elbow is also called:

Pulled elbow

Radial head subluxation

Annular ligament entrapment

Prevention

The principal preventive measure is to avoid sudden traction on a young child’s arm.

Parents and caregivers should avoid:

Pulling or lifting a child by one hand or forearm

Swinging a child by the arms

Jerking the arm when the child pulls away

The child should instead be lifted by supporting the trunk or under the arms.

Epidemiology

Nursemaid’s elbow most commonly affects children between:

1 and 5 years of age.

It is one of the most frequent elbow injuries encountered in young children.

Historically, boys and girls have been considered to be affected with similar frequency, although some series report a slight female predominance.

Risk Factors

Important risk factors include:

Age between 1 and 5 years

Previous nursemaid’s elbow

Sudden pulling or traction on the arm

A young child pulling away from an adult who is holding the hand can create the classic mechanism.

Genetics

There is no known genetic predisposition.

Etiology

The injury usually occurs when the forearm is subjected to longitudinal traction while the elbow is extended, often with the forearm pronated.

This can happen when:

A parent pulls the child upward by the hand

A sibling pulls the child’s arm

The child suddenly pulls away while being held

Annular Ligament Injury

With traction, part of the annular ligament may slip over the radial head and become trapped within the radiocapitellar joint.

The ligament may be:

Stretched

Partially torn

or

Displaced into the joint

This produces pain, particularly with forearm rotation.

Typical Mechanism

The classic mechanism is traction rather than a fall.

A fall onto an outstretched hand is more likely to cause another injury, such as:

Distal radius buckle fracture

Supracondylar humeral fracture

Other elbow fracture

Therefore, a history of substantial trauma should prompt consideration of an alternative diagnosis.

Diagnosis

The diagnosis is usually clinical.

Signs and Symptoms

Typical findings include:

Sudden elbow or forearm pain after a traction injury

Refusal to use the affected arm

Minimal tenderness

Little or no swelling

Absence of obvious deformity

Arm Position

The child commonly holds the affected arm:

Close to the side

with the elbow slightly flexed or extended and the forearm often pronated.

The child avoids spontaneous use of the limb.

Palpation

There is usually:

Minimal focal tenderness

and

No substantial swelling or bruising.

Marked tenderness, swelling, ecchymosis, or deformity should raise concern for fracture or another diagnosis.

Diagnostic Response to Reduction

The most characteristic diagnostic feature is rapid return of function after successful reduction.

Within several minutes, the child often begins to:

Reach for objects

Flex the elbow

Rotate the forearm

Use the arm normally

Residual tenderness should be minimal or absent.

Physical Examination

Examine the entire upper extremity before attempting reduction.

Assess for:

Swelling

Ecchymosis

Deformity

Focal bony tenderness

Skin injury

Neurovascular abnormalities

If these features are absent and the history is classic, nursemaid’s elbow is highly likely.

Laboratory Tests

No laboratory test is useful for diagnosing nursemaid’s elbow.

Laboratory studies should only be considered when another condition such as:

Infection or inflammatory disease

is suspected.

Imaging

Radiographs are not routinely required when:

The history is classic

There is no swelling or deformity

The examination is otherwise reassuring

Indications for Radiographs

AP and lateral elbow radiographs should be considered when:

The mechanism is atypical

A fall or direct trauma occurred

There is focal bony tenderness

Significant swelling or bruising is present

Reduction fails

The child continues to refuse use of the arm after reduction

Radiographic Findings

In a true nursemaid’s elbow, radiographs are generally:

Normal.

The purpose of imaging is primarily to exclude:

Fracture or other structural injury.

Pathological Findings

The annular ligament may be:

Stretched, partially torn, or displaced into the radiocapitellar joint.

Complete rupture is not usually present.

Because the condition resolves readily and surgery is almost never required, pathologic specimens are rarely available.

Differential Diagnosis

Important alternative diagnoses include:

Supracondylar humeral fracture

Distal humeral buckle or greenstick fracture

Radial neck fracture

Distal radius fracture

Physeal injury

Elbow infection

Juvenile idiopathic arthritis

Lyme arthritis

These disorders are considerably less common than nursemaid’s elbow in a child with a classic traction mechanism and minimal examination findings.

Fracture Versus Nursemaid’s Elbow

Features favoring a fracture include:

Fall or direct trauma

Substantial swelling

Bruising

Focal bony tenderness

Persistent pain after attempted reduction

Treatment

General Principles

Treatment consists of closed reduction of the displaced annular ligament.

Sedation is usually unnecessary.

Two commonly used techniques are:

Hyperpronation

and

Supination-flexion.

Hyperpronation Technique

The examiner supports the elbow and rapidly but gently pronates the forearm.

A subtle:

Click or pop

may be felt near the radial head.

This technique is commonly effective and may have a high first-attempt success rate.

Supination-Flexion Technique

The traditional maneuver involves:

Supinating the forearm

followed by

Full flexion of the elbow, bringing the child’s hand toward the shoulder.

A small click may be felt during reduction.

Response After Reduction

The child may initially remain upset because of fear or discomfort.

Successful reduction is usually followed within several minutes by spontaneous use of the arm.

The child should be observed until normal use returns.

Analgesia and Sedation

Sedation is generally not required.

Medication is often unnecessary after successful reduction.

If needed, a simple analgesic such as:

Acetaminophen

may be used.

If severe or persistent pain requires stronger analgesia, another diagnosis should be reconsidered.

Immobilization

A sling or splint is usually unnecessary after a first uncomplicated episode.

Immobilization may occasionally be considered after:

Repeated recurrence

or when discomfort persists despite successful reduction.

Activity

After successful reduction, the child may return to:

Normal age-appropriate activity as tolerated.

Parents should be advised to avoid pulling or swinging the child by the arms.

Physical Therapy

Physical therapy is not required.

Children regain normal motion and function spontaneously after reduction.

Surgery

Surgery is not indicated for uncomplicated nursemaid’s elbow.

Persistent inability to reduce the injury should prompt:

Reassessment of the diagnosis and appropriate imaging, rather than repeated forceful manipulation.

Follow-Up

Routine follow-up is usually unnecessary once the child resumes normal use of the arm.

Prognosis

The prognosis is excellent.

Most children recover completely without:

Pain

Loss of motion

Growth disturbance

Long-term elbow dysfunction

Recurrence

Some children experience recurrent nursemaid’s elbow.

Repeated episodes can generally be treated with the same reduction technique.

Recurrence becomes less common with age as the radial head enlarges and the annular ligament becomes more firmly attached.

Children usually outgrow the predisposition by approximately 5–6 years of age.

Recurrent Cases

In selected children with repeated episodes, brief immobilization for approximately:

1–2 weeks

may occasionally be used, although most recurrent episodes still require only reduction and parental education.

Complications

Nursemaid’s elbow itself generally has no significant long-term complications.

The most important potential problem is:

Misdiagnosis.

Missed Fracture

A fracture may be overlooked if an atypical presentation is assumed to be nursemaid’s elbow.

Warning signs include:

Significant swelling

Bruising

Focal tenderness

Deformity

A history of a fall or major trauma

Failure to regain arm use after reduction

Patient Monitoring

No ongoing monitoring is required after successful reduction and return of normal function.

Further evaluation is required when:

Pain persists

The child continues to avoid using the arm

Swelling develops

Reduction is unsuccessful

Key Principle

Nursemaid’s elbow is a traction-related annular ligament injury in young children that typically presents with refusal to use the arm despite minimal swelling or tenderness.

The classic features are:

A traction mechanism, a reassuring examination, successful closed reduction, and rapid return of normal arm use.