Nursemaid Elbow 101: Causes, Symptoms and Treatment

Nursemaid elbow has many names: pulled elbow, radial-head subluxation, annular ligament displacement. Basically, it is when the elbow is pulled into malalignment or partially dislocated. Whatever you decide to call it, it is pretty scary the first time it happens to your kid. If you aren’t there to witness the trauma, you may just see your child withholding from using the affected limb like it is paralyzed. Your child may not even seem to be in pain, but may cry at your attempts to touch or move the arm. Is it broken? All the “what-ifs” or the speculation on what could have possibly happened runs through your head, along with the immediate guilt you feel if it happens when you picked up your little one or you were holding hands. But I can assure you —it’s not your fault.

The median age for the occurrence of nursemaid elbow is about 2 ½ years old. It happens to girls more than boys and the left arm more than the right, and is more common in kids in about the 75th percentile in weight. However, it can still strike any child.

It happened to my son’s left and right arms and he falls steadily in the 50th percentile. So although he doesn’t exactly fit the profile, he has a mommy who has ligament laxity. Poor guy is genetically predisposed.

The first time it happened to my son, he was about 18 months, and the last time it happened was just last month (he’s 3 now). It can happen simply because you’re holding your child’s arm when he or she trips, and you reflexively hold on tighter to stop the fall. It can happen during rough-and-tumble play. For those loosey-goosey kiddos like my son, it even happened when he was shaking a chain-link fence. Do you see what I’m getting at? It happens, so skip the guilt; it’s not your fault. Toddlers are more prone because, well, we hold their hand to keep them safe … but they fall or impulsively change directions without notice. In addition, toddlers’ anatomy differs. The radial head is smaller and the annular ligament is thinner. So basically what that means is, the toddler arm easily slips out of its socket.

Now that you know the common risk factors for nursemaid elbow, you can try to prevent it. Now, I realize that we can’t prevent it from happening all the time (I refuse to make my child a bubble boy), so it also helps to know the signs and symptoms.

Signs/Symptoms

• History of prior incidents of nursemaid’s elbow
• Witnessing of the event that caused the injury or dislocation
• Pain with movement
  • Typically with supination/pronation (hand faceup, then down) rather than flexion/extension from the elbow (elbow bent, then straightened)
• Pseudoparalysis – child voluntarily keeps the limb still
  • Typically with hand facedown
• Elbow slightly bent
• Possible tenderness at the outside point of the elbow
• Persistent complaints of pain despite no visible dislocation, deformity, bruising, swelling or injury– if so, contact your physician**

Two Techniques to Resolve Pulled Elbow

Although each of the two techniques is used widely by pediatricians, research suggests that hyperpronation is more effective and less painful than supination. For my son, we have had to use both. When the first doesn’t work, we try the other. I typically feel a “click” that seems to come from his wrist (even though the ligament clicking back into place is at the elbow). I know he’s good when he is able to lift up the affected arm and give me a high-five and a smile.

Hyperpronation Technique (Moving hand toward thumbs down position)

• Hold the child’s hand as if you are going to give him or her a handshake.
• Support the elbow with your other hand.
• Move the hand toward thumb facedown.
• When you feel or hear a click, the elbow is reset
• Pain should subside and movement should return.

Supination Technique (Moving hand toward palm face up)

• Hold the elbow (supporting the radial head – the bone that sticks out the side of the elbow) and the hand on the affected arm.
• Move the hand to palm faceup (wrist extended).
• Flex the elbow.
• When you feel or hear a click, the elbow is reset
• Pain should subside and movement should return in five to 30 minutes.

*Always contact your physician for counsel and advisement on your child’s health issues. This article is provided as a reference and does not replace medical care under the supervision of your practitioner.