Nursemaid’s elbow, known medically as radial head subluxation, is a common pediatric injury that occurs when a bone in the forearm partially slips out of its normal alignment at the elbow joint. This injury is frequently called “pulled elbow” because it is typically caused by a sudden, sharp pull on the child’s hand or wrist. The condition is painful but temporary and does not cause long-term damage once properly treated. The injury involves the radial head slipping beneath the annular ligament that normally holds it in place.
Recognizing the Signs of Radial Head Subluxation
Radial head subluxation is most common in children between the ages of one and four years old, though it can occur up to age six or seven. The injury is usually easy to identify because of the clear history of a pulling mechanism, such as being lifted by the hands or being swung by the arms. Following the injury, the child will typically cry immediately due to the sudden pain.
The most telling sign is the child’s refusal to use the affected arm. They will often hold the arm still, pressed against their body with the elbow slightly bent and the palm turned downward. Unlike a fracture, nursemaid’s elbow usually presents without any noticeable swelling, bruising, or deformity around the joint. If a caregiver attempts to turn the child’s palm upward, a movement known as supination, the child will resist and experience increased pain.
Immediate Steps and When to Seek Medical Attention
If a child experiences a sudden pull on the arm and then refuses to use it, seeking professional medical attention is the correct next step. A trained healthcare provider needs to confirm the diagnosis, as the symptoms of a pulled elbow can sometimes resemble other conditions, including a fracture. It is important to keep the child calm and avoid trying to move, force, or straighten the arm, which could cause further distress.
Attempting to treat or “pop” the elbow back into place without medical training is strongly discouraged. The healthcare provider must first rule out other injuries, which may involve taking an X-ray if there is any suspicion of a fracture or if the mechanism of injury is unclear. Once a fracture is excluded, the professional can perform a swift, non-surgical maneuver to correct the subluxation.
Professional Reduction Techniques
The solution for nursemaid’s elbow involves a closed reduction, which is a quick manipulative technique performed by a medical professional to guide the radial head back into its correct position. This procedure is typically done without the need for sedation and can be completed in a few seconds. There are two primary methods used for this reduction: the supination-flexion method and the hyperpronation method.
Supination-Flexion Method
The supination-flexion technique involves the provider holding the child’s elbow while applying pressure over the radial head. The provider then rapidly turns the palm upward (supination) and fully bends the elbow (flexion). This was historically the standard technique, aiming to maneuver the trapped annular ligament back over the radial head.
Hyperpronation Method
The hyperpronation method is often preferred due to its higher reported first-attempt success rates and potential for causing less discomfort. With this technique, the provider supports the elbow and then quickly and firmly turns the forearm palm-down, or hyperpronates the wrist.
With both maneuvers, a subtle “click” or “pop” may be felt or heard as the radial head slips back into place. The characteristic click confirms the successful reduction. Following this maneuver, most children experience immediate relief and will begin to use the affected arm normally within minutes, often within five to ten minutes. If the first attempt is unsuccessful, the medical professional may attempt the same technique again or switch to the alternative method.
Recovery and Avoiding Recurrence
After a successful reduction, no splinting or sling is typically necessary, and the child should be encouraged to use the arm normally right away. The return to full arm function within a short period confirms the success of the procedure. In rare cases where the child does not regain arm use, further evaluation may be needed to check for other issues.
Once a child has experienced nursemaid’s elbow, there is an increased likelihood of it recurring, especially in the weeks following the initial injury. Caregivers should focus on prevention by avoiding activities that involve longitudinal traction on the arm.
This means never lifting a child by their hands, wrists, or forearms, and refraining from swinging a child by their arms during play. Instead, children should be lifted by grasping them gently under the armpits or by supporting the trunk of the body.