Radial head subluxation, commonly known as Nursemaid Elbow, is a frequent orthopedic injury in young children. It involves the partial displacement of a forearm bone at the elbow joint. The injury occurs when the annular ligament, which acts like a sling around the top of the radius bone, slips out of position and becomes trapped. This displacement is typically seen in children aged one to four years, usually following a sudden, strong pull or traction applied to the hand or forearm, such as when a caregiver quickly lifts or swings the child.
Identifying the Injury
The diagnosis of Nursemaid Elbow relies on the child’s history and observable symptoms. Following the pulling incident, the child shows a sudden refusal to use the affected arm. They hold the arm close to the body, slightly bent at the elbow, with the forearm turned inward (pronated).
The child resists any attempt to move the arm, especially rotation of the forearm. Unlike a fracture, the injury site shows no noticeable swelling, bruising, or deformity. The child is usually in little distress unless the elbow is actively manipulated. This classic presentation allows healthcare professionals to make a clinical diagnosis without needing X-rays.
How Healthcare Professionals Restore the Elbow
Treatment involves a manual procedure called “reduction,” which moves the displaced ligament and bone back into position. This quick maneuver must only be performed by a trained healthcare professional, such as a doctor, nurse practitioner, or physician’s assistant, to prevent further injury. Two primary techniques are used for reduction: the Supination-Flexion method and the Hyperpronation technique.
The Supination-Flexion technique requires the practitioner to support the child’s elbow. They first rotate the forearm outward (supination) and then fully bend the elbow (flexion). This maneuver aims to guide the trapped annular ligament back over the radial head. Historically, this was the most common approach, but recent studies suggest it is less effective on the first attempt.
The Hyperpronation technique is often favored as the first-line treatment due to its higher success rate and reduced pain. This method involves holding the elbow bent at a 90-degree angle and forcibly rotating the forearm inward (hyperpronation). Clinical data shows this maneuver achieves successful reduction on the first attempt in approximately 85% to 94% of cases.
The entire procedure takes only a few seconds. Successful reduction is often confirmed by an audible or palpable “pop” or “click” as the ligament returns to its normal position. The most reassuring sign of success is the child’s immediate cessation of pain and the spontaneous resumption of arm movement, often within minutes. If the first technique fails, the provider immediately attempts the alternative method, resulting in a near 100% success rate when used sequentially.
Avoiding Future Incidents
The stretched annular ligament may be temporarily weakened after an incident, making the elbow susceptible to recurrence in the following weeks or months. Preventative measures focus primarily on avoiding the specific type of traction injury that caused the initial subluxation. Caregivers should never lift or swing a child by holding their hands, wrists, or forearms.
It is important to avoid sudden, forceful tugs on a child’s arm, such as when pulling them quickly or preventing a fall. When lifting a child, support should be placed under the torso or armpits to eliminate direct pull on the elbow joint. This advice should be communicated to all caregivers, including babysitters and older siblings, to minimize the risk of accidental recurrence.
This injury rarely occurs after a child reaches five or six years of age. As the child grows, the ligaments naturally become thicker, stronger, and less elastic. Furthermore, the radial head develops a shape that makes it harder for the annular ligament to slip out of place. Due to this natural maturation of the joint structure, the child eventually outgrows the risk of Nursemaid Elbow.