Nursemaid’s Elbow

Nursemaid’s elbow results from injury to the annular ligament that surrounds the radial head at the elbow in a young child (Fig. 1).

The injury causes guarding and failure to use the elbow.

It is not a subluxation or dislocation.

Synonyms: Pulled elbow; Annular ligament entrapment

It usually affects children 1–5 years old (1).

Boys and girls are affected equally.

Ages 1–5 years

Stubborn behavior (pulling away)

With traction, a small part of the
annular ligament that surrounds the radial head is pulled toward the
joint and may be partially torn, causing painful rotation of the radius.

This injury usually does not result from
a fall on the outstretched hand, which typically produces a buckle
fracture of the distal radius or an elbow injury.

Pain in the elbow after a traction injury, such as pulling on the arm by a parent or sibling (Fig. 2)

Usually, minimal pain to palpation

No substantial swelling

Resistance by the patient to use the elbow

The response to reduction of the
displaced ligament is the most diagnostic feature of all: The child
starts using the elbow again shortly, and no residual tenderness is
present.

Buckle or greenstick fracture of the distal humerus

Growth plate injury of the distal humerus or proximal radius

Infection, juvenile rheumatoid arthritis,
and Lyme disease, which are all possibilities but which occur much less
frequently than nursemaid’s elbow

Rule out other conditions (usually by physical examination).

Reduce the displaced annular ligament by
flexing the child’s elbow fully, bringing the child’s hand up to touch
the shoulder, while supinating the forearm (Fig. 3).

A sling or splint usually is not needed unless the episode is a recurrence.

Medications usually are not needed once the injury is reduced, but acetaminophen may be given.

If stronger medication is needed, suspect another diagnosis.

Not needed

Closed manipulation is always successful.

The prognosis usually is excellent; there should be no sequelae.

A few children suffer a recurrence, which can be reduced and splinted for 1–2 weeks.

Sometimes several recurrences may happen within a year, but the child will eventually “grow out” of this predisposition.

None are known, except misdiagnosis, such as missing a fracture about the elbow.

This condition can be distinguished from a fracture by the latter’s different mechanism and greater swelling and tenderness.

Educate parents about the traction mechanism of the injury and the need to avoid pulling on the child’s elbow.

If a child has had several recurrences,
it is appropriate for a parent to learn the reduction maneuver so that
it can be handled at home.