Nursemaid's elbow is an injury to the ligament (strong band of tissue) that keeps the two bones of the forearm in the correct place.
Description
The two bones in the forearm are the radius and the ulna. The radius is on the thumb side of the forearm. The upper end of the radius is called the radius head. The radial head is held in place by a ligament called the annular ligament. When the annular ligament is torn, a part of it slides upward and becomes trapped in the elbow joint, which is very painful condition. The child holds the arm with the palm facing inward and the elbow bent. This injury is uncommon after the ages of three to four, due to stronger joints and ligaments. Also, youngsters are less likely to be in situations where this injury might occur.
Nursemaid's elbow is a common occurrence in children from the ages of one to four or five. It is rarely seen after the age of six.
Causes and symptoms
Nursemaid's elbow is caused by a strong force on the elbow, such as a sudden pulling or yanking on the hand or forearm. This can occur when a child falls, when an adult pulls up a child's arm, to assist the child up a curb or step or to hurry the child along, or when a child falls away from an adult while being held by the arm. Swinging toddlers from the arms while playing can cause this injury. It can also occur when an infant rolls himself or herself over.
Symptoms of nursemaid's elbow include immediate pain in the injured arm, refusal or inability to move the injured arm, creating a condition called pseudo-paralysis, persistent crying, refusal to play, and anxiety. However each child may experience symptoms differently. These symptoms may also resemble other conditions or medical problems, so a physician should be consulted for a diagnosis.
When to call the doctor
The doctor should be called or the child should be taken to an emergency room when a child does not use the arm that has been injured, when the child seems to be in a lot of pain, or when there is a suspicion that someone has deliberately harmed the child.
After treatment for nursemaid's elbow, the doctor should be called if the child still refuses to use the arm six hours after it is put back into place; the child still has pain after 24 hours; the child's fingers get numb and tingly; or the child's elbow comes out of the socket again.
Diagnosis
The diagnosis of nursemaid's elbow is made through a physical examination by the child's physician. X rays of the elbow are usually not necessary.
Treatment
The child's arm should not be straightened or its position changed before the doctor examines it. An ice pack can be used, and the arm splinted in the position in which it is found. The area both above and below the elbow should be immobilized, including the shoulder and wrist if possible.
The physician or health care provider will move the bone and ligament back to their correct positions. This is an easy procedure that can be done in the office by supinating (externally rotating) the forearm (turning the thumb out with palm up), and then gently flexing the arm at the elbow (pushing the forearm up into the biceps). The ligament needs time to heal, so the child's arm should be treated gently after the procedure. The arm may be immobilized in a sling for one or two days, if desired.
Once the ligament and the radial head are returned to their proper position, the child can usually begin to use his or her arm again within a few minutes. Sometimes there is a short period of crying for a minute or two after the release. The earlier after the injury that the child is treated, the more rapid will be the recovery. Alternatively, if the problem has existed for some days, then relief from pain may not be so rapid. Bracing and immobilization
is usually not required if this is the first occurrence of this condition. For repeat injuries, however, a posterior splint may be applied for several days. A few children may have swelling or pain in the joint. Regular doses of ibuprofen or other over-the-counter pain killers for a few days will help with the swelling and the pain.
If the child fails to use the arm after 15 minutes, the elbow should be x rayed to determine if it was fractured. If no fracture is found, the arm should be splinted and put into a sling, and the condition re-evaluated after 24 hours.
Prognosis
The child should be able to use the elbow after the injury has healed. However, once an elbow has been injured, it is more likely that it will happen again in the future if care is not taken to prevent further injury.
Prevention
A child should not be lifted or swung by the arms or hands nor should a child's arm be pulled hard. A small child should be lifted from under the arms.
Parental concerns
Parents should be aware of the damage to the ligament structures of the elbow and should not lift the child by the arm, as the pulled-elbow condition can reoccur up. Recurrence is especially likely for three to four weeks following the injury.
Unfortunately, nursemaid's elbow commonly occurs when an obstinate child is forcibly pulled along or lifted by the forearm by a parent or older sibling. For example, the injury might occur in a shopping center where a young child, typically two or three years old, is intent on pursuing a course or selecting an item somewhat different from the intentions of the parent. Another scenario that might result in nursemaid's elbow is when a parent or caregiver and a child are crossing the street where the parent or caregiver is forced to pull the child along quickly to avoid an approaching vehicle or to make it to the other curb before the traffic lights change. Care should also be taken to control anger or impatience to prevent re-injury in the future.
KEY TERMS
Elbow—Hinged joint between the forearm and upper arm.
Ligament—A type of tough, fibrous tissue that connects bones or cartilage and provides support and strength to joints.
Nursemaid's elbow—An injury to the ligament (strong band of tissue) that keeps the two bones of the forearm in the correct place.
Radius—The bone of the forearm which joins the wrist on the same side as the thumb.
Ulna—One of the two bones of the forearm. Two pivot joints join it to the radius, one near the elbow, one near the wrist.
BOOKS
PM Medical Health News. 21st Century Complete Medical Guide to Elbow Injuries and Disorders: Authoritative Government Documents, Clinical References, and Practical Information for Patients and Physicians. Washington, DC: Progressive Management, 2004.
