A nursemaid’s elbow is the common name for a radial head subluxation, which is an injury that is unique to children, typically occurring around 6 months to 3 years of age. The injury occurs when a ligament that surrounds the swivel joint of the radius (in the elbow) slips away from the bone and becomes trapped. This usually occurs when the arm is pulled, usually while playing or lifting a child by the arm. The child will often start crying and be unwilling to move the arm, crying with attempts to straighten. You should not see any swelling to the area and if so, fracture has to be a consideration. Also, when there has been significant trauma such as a fall from height, a broken bone is a likely alternate possibility.
As a parent it is often not clear why your child is in pain and It can be scary to see your child not wanting to move his or her arm. It may be surprising, but based on history and exam alone we as emergency physicians will often recognize this injury and be able to fix it on the spot without x-rays. The procedure of fixing or “reducing” the injury causes brief pain but is tolerated very well by children with almost instantaneous relief in discomfort and return to normal activity without restriction. We do not expect you to try this on your own if you have not been instructed on how to do it, but once you have recognized that your child has a recurrence and hasn’t had any concerning trauma, it is often a procedure that you can do on your own.
Hyperpronation is a relatively simple method used to fix the nursemaids elbow and what is preferred by me. With the child seated in someone (parent’s) lap, facing the person performing the procedure, the radial head is felt as a bump on the lateral (outer) part of the elbow. You can best feel this with your thumb (try on yourself) but putting the hand facing upward underneath the child’s elbow. Put mild pressure on it so you can feel, but not so much that it hurts. Hold the elbow firm so that the upper arm is stable. With your other hand turn the hand inwards so that it is facing downwards. In fact, there is a lot of flexibility and the hand will go well beyond that point, seemingly further than it should. By doing so you will feel a “click” on your thumb as the annular ligament slips back in place. If you don’t feel the click try again with even more tension as you rotate the hand around. If after a few attempts your child is not better we recommend you have your child seen by us or your local emergency provider.
The supination/flexion technique is similar and initiated with the same positioning of the child and person performing the procedure. As before, your hand is placed under the elbow with the thumb on the radial head and held firm and stable. With the opposite hand, the child’s hand is held facing palm-upwards then flexed (bent) upwards towards the shoulder. Again, you should be able to feel a click at the radial head.
After successful reduction the child may still be apprehensive about moving it but soon after will start using it on his/her own and progressively realize that there is no pain. At that point he or she will not have any restrictions other than avoiding similar pulling motion to that arm. If the child continues to be hesitant to move, in pain, or have any apparent limitation, we recommend evaluation. If you have any questions or would like us to see your child for evaluation, call us at 408-256-1117 to speak immediately to your local BMC physician.