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Synonyms: nursemaid's elbow, babysitter's elbow, pulled elbow
This is a common injury and occurs under the age of 6 years, in part because the mechanism of injury puts this age group at risk. Toddlers will often walk holding the hand of a taller adult or older child and, whilst so held, fall more easily. More significantly there is also an anatomical predisposition to subluxation of the radial head in children aged under 6 years. At this age the end of the radial head is still rounded and made of cartilage. It can thus quite easily slip out of the encircling annular ligament when the arm is pulled, usually tearing some fibres of the softer young ligamentous tissue.
Symptoms after only minor or no trauma mean that puzzled, anxious parents may consult a GP rather than attending hospital. It is important to diagnose and treat this condition promptly. Treatment can be very gratifying for all and, if prompt, can avoid unnecessary pain and anxiety. It is important to appreciate the differential diagnosis and to recognise atypical cases because investigation (eg, X-ray) and/or referral are necessary.
- It usually occurs between the age when children start walking (around age 1 year) and age 4 years (when they fall more often). The peak age of incidence is around 2 years.
- It is often referred to as the most common orthopaedic injury in those under age 2 years.
- It is less common over the age of about 5 years but can still occur for anatomical reasons until about age 6 years.
- Girls are more commonly affected than boys and it occurs slightly more often in the left hand, as adults are more often right-handed (thus holding children by the left hand).
- It occurs very rarely in young adults.
- The age and history usually suggest the diagnosis.
- There is often no history of trauma.
- There is usually a history of elbow pain, sudden crying and characteristic upper limb immobility:
- The arm is moved at the shoulder but not at the elbow.
- The elbow is held slightly flexed and pronated.
- The forearm is often held against the abdomen.
- Pain is centered around the radial head.
- Often, on closer questioning, the arm has been pulled axially. Such axial traction may have occurred:
- Just pulling an arm through a sleeve whilst dressing.
- Lifting a child by one hand up and over an object.
- Picking up or trying to prevent a child falling whilst holding hands.
- Moving in opposite directions quickly whilst holding hands.
- Examination usually confirms the diagnosis.
- The child is usually apprehensive and protects the affected arm.
- Anxiety predominates over pain.
- The arm is held as above flexed slightly between 15° and 20°.
- The child may support the affected hand against the abdomen or with the unaffected hand.
- There is no systemic illness, warmth or swelling (these suggest other causes).
- The child is reluctant to move not only the elbow but also the wrist and fingers (in case this moves the elbow).
- Tenderness at the radial head is present.
- Flexion, extension, pronation and supination of the forearm are all resisted.
- Congenital dislocation of the radial head.
- Fractures affecting upper limb mobility: (always consider the possibility of non-accidental injury):
- Other causes of an immobile upper limb, for example:
- Imaging studies (including X-rays) are not usually necessary.
- X-rays are required when:
- A fracture is suspected because of significant tenderness with swelling, bruising or deformity.
- Reduction is unsuccessful after two or three attempts.
- Ultrasound can be used to evaluate the annular ligamentous injury and show displacement of the radial head from the capitellum. However, this technique is still being evaluated and is not usually used acutely. It has been used to evaluate patients who have recurrent dislocations.
- MRI studies can be used to confirm subluxation and assess ligamentous damage. Again this would usually only be used for recurrent cases where significant ligamentous damage is suspected.
If the diagnosis can be confidently made and there is no suggestion of a fracture after careful history and examination, pulled elbow can be managed in the primary care setting. Indeed, this can prevent delay and reduce the child's pain and anxiety more quickly. Key points are as follows:
- It can be gratifying to treat because function is quickly restored.
- Manipulation should be performed only after careful examination to restore the radial head to its correct position within the annular ligament. Broadly, two techniques have been described and these are both simple, effective and well described with pictures in an article from Melbourne.
- There is limited evidence that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children.
- After successful reduction it may take half an hour for normal function to return. In children aged under 2 years, and where there has been a delay of more than four hours before reduction, return to normal function may take longer.
- If manipulation is successful and function is restored no further treatment or investigation is required. If unsuccessful after two or three attempts and a suitable wait for restoration of function then referral for further assessment and X-rays is necessary.
- To prevent recurrence, education of parents, grandparents, siblings, and carers is essential after reduction. Such education is essentially to describe the nature and mechanism of injury, with particular emphasis on scenarios likely to produce recurrence.
Manipulation technique: supination
- Grasp the affected elbow with one hand to immobilise the elbow and palpate (locate) the radial head (usually with the thumb).
- With the other hand apply axial compression ('pushing in') whilst supinating the forearm and flexing the elbow.
- A click or snap will be felt over the radial head, confirming accurate relocation.
- Some suggest slight pressure at the radial head.
- Some suggest extension rather than flexion of the elbow, but there is some evidence to suggest this is less effective.
Manipulation technique: pronationThis may be more effective:
- Grasp as above, applying pressure over the radial head with one hand (allow the thumb to palpate the radial head).
- Pronate and flex the elbow with the other hand whilst grasping the affected wrist.
- Relocation should be felt as above.
- Follow-up is not routinely required if reduction is felt and function restored. However, a quick consultation to confirm restoration of function and reiterate preventative advice is good practice.
- If referral and radiographs were required and reduction was apparently unsuccessful then GP follow-up is required. This is to confirm reduction and restoration of function with the GP after 24 to 48 hours.
- A sling may be offered to support the arm over this time. Either spontaneously or otherwise, some patients who have not enjoyed restoration of function half an hour after manipulation will do so by day four after manipulation.
The radial head may fail to reduce. This is rare.
Prognosis is excellent.
- This is an important part of management.
- Education of the whole family is appropriate.
- Education comprises:
- Avoiding lifting children by one arm.
- Avoiding lifting or swinging by arms.
- Description of the mechanism of injury.
Further reading and references
Nursemaid's Elbow; Medline Plus
Nursemaid's Elbow (Radial Head Subluxation); Wheeless' Textbook of Orthopaedics
Pulled Elbow, Clinical Practice Guidelines; Royal Children's Hospital, Melbourne
Lewis D, Argall J; Reduction of pulled elbows. Emerg Med J. 2003 Jan20(1):61-2.
Krul M, van der Wouden JC, van Suijlekom-Smit LW, et al; Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2012 Jan 181:CD007759. doi: 10.1002/14651858.CD007759.pub3.