After a long, frustrating day of shopping, Evan’s mother, in her attempt to prevent an injury, pulled 2-year-old Evan by his right arm as a car came speeding through the parking lot. He immediately shrieked in pain and grabbed his elbow, crying “owie, owie”. His mother stood in disbelief wondering what could be wrong since his elbow looked completely normal. He refused to bend the elbow but settled down over the next couple of minutes, so they journeyed home.

Over the next hour, he continued to let his arm hang at his side, not allowing anyone to bend it. His mom called his pediatrician who encouraged her to bring Evan in for a manipulation of his nursemaid’s elbow.

What is nursemaid’s elbow?

Nursemaid's elbow, or pulled elbow, is a subluxation of the radial head near the elbow joint caused by a sudden pull on the extended arm. Normally, the radial head is held in a stable position next to the ulna by the annular ligament providing stability of both of the bones at the elbow. The ligament’s normal position is at the narrow “neck” portion of the radius. With a longitudinal pull, the wider radial “head” is entrapped beneath the annular ligament. Because the ligament is being stretched, it is uncomfortable for the child.

Is nursemaid’s elbow common?

Radial head subluxation is a common pediatric presentation generally occurring between the ages of 1 and 3 years, although it can happen anytime between 6 months of age and 7 years. After age 3, children's joints and ligaments gradually grow stronger, making radial head subluxation less likely to occur.

What are the symptoms of nursemaid’s elbow?

When the radial head is subluxed, the child initially complains of pain and then stops using the arm, ignoring it during play activities. The arm is held at the child’s side in an extended position with the forearm pronated “palm down”. When the caregiver or doctor tries to bend the elbow the child cries in pain. There is negligible swelling and the contours of the elbow appear entirely normal.

How is nursemaid’s elbow diagnosed?

The most important part of diagnosis is a history of longitudinal traction on the arm. The caregiver plays an important part in providing this kind of accurate information. In the case of an unwitnessed injury, x-rays may be required to rule out a fracture. With nursemaid’s elbow, the appearance of the elbow and the x-rays are entirely normal.

How is nursemaid’s elbow treated?

Nursemaid’s elbow can be treated in the physician’s office. The affected arm must be held while the forearm is de-rotated and the elbow is flexed until the hand touches the shoulder. The physician will usually feel a "click" if the maneuver is done properly, the child will feel momentary pain which subsides over the next 5 minutes. If this maneuver is performed within the same day as the injury, the child will use the arm in a typical, painless manner. In the case of a delayed manipulation, there may be some prolonged recovery that is aided with the use of anti-inflammatory medications. Rarely is a splint, cast, or sling necessary.

What is the long-term outlook for my child?

The vast majority of children with nursemaid’s elbows will recover full function with no risk of recurrence. There are however rare cases where frequent radial head subluxations plague a child. Occasionally immobilization in a cast may be helpful. Nearly all recurrences will resolve by the age of 5.

At the doctor’s office with the history provided by Evan’s mother, the diagnosis of nursemaid’s elbow was confirmed. The simple manipulation resulted in a “click” at the elbow that even Evan’s mother could hear. After 3-4 minutes of fussing, Evan began to play with the toys in the office using both hands equally. The pediatrician looked at Evan’s mom and said “are you o.k.?” She responded, “I feel so guilty.” The pediatrician reassured her, “you were acting on a mother’s instinct when you saw the car coming, who knows what would have happened otherwise.”