Nursemaid Elbow (Pulled Elbow)

This common pediatric condition refers to radial head subluxation (radiocapitellar joint of the elbow complex) generally occurring between the ages of 1 and 4 years, although it can happen anytime until the age of 7. At that age, the soft tissues, including muscles and bones still continue to develop that even a mild sudden pulling force on the extended pronated forearm produce a partial dislocation. Children at this age are very active in their play activities such that tugging a child or by swinging them around or back and forth by the arms causes the bone to slip out of its normal place at the joint.




Left elbow-joint Left: anterior and ulnar collateral ligaments Right: posterior and radial collateral ligaments (Photo credit: Wikipedia)





Causes:

• Catching a child by holding the hand or wrist to stop a fall.
• Pulling a child up by the hands or wrists to keep out of danger or lifting a child over a high step
• When an adult swing a child by holding the arms or hands.
• Quickly grabbing a child's hand or wrist to walk faster or even pulling a child hand along while walking
• Pulling a child hand through a long-sleeve jacket 
• An infant rolls over in an unusual way in a crib, bed, or in the floor

Signs and Symptoms:

• Moving the injured arm is painful, especially supination
• The child injured arm is kept on his/her side, usually held in flexion and pronation
• Minimal swelling

Differential Diagnoses:

• Elbow Fracture
• Soft Tissue, Hand or Wrist Injury
• Wrist Fracture 

Brief Anatomy:


The bone of the upper arm (humerus) and the two bones of the forearm (radius & ulna) made up the elbow complex. Medial collateral ligament, lateral collateral ligament, and the annular ligament holds the joint together to prevent dislocation. The joint complex has 2 joints namely, the proximal radioulnar joint for flexion & extension and the radiocapitellar joint for forearm pronation & supination.

Diagnosis:

• History of injury
• Physical examination
• A child is reluctant to move the injured arm because of pain
• The injured arm is kept on the side.
• The forearm is usually flexed and pronated
• Some tenderness at the radial head area

Imaging:

• X-ray to rule out possible fracture but are often unnecessary
• Ultrasonography and MRI performed to confirm ligament involvement

Treatment:

• A reduction is a gentle maneuver that allows the bone to go back into its normal place. If unsuccessful after 2-3 attempts, X-ray is needed to rule bone fracture. 
• Over-the-counter pain medicine, such as acetaminophen or ibuprofen may be given. Never give aspirin to a child under age 12.

Prognosis:

• It is usually excellent with treatment. If left untreated, the child may be permanently unable to fully move the elbow. 

Prevention:

• The most important thing is to know the risk 
• Avoid tugging or pulling a child's hand or wrist
• Never swing a child by holding the hand or wrist
• Never lift a child by holding the hand or wrist instead grasp under the arm
• Some children are more likely to get it again, a doctor may teach the family the reduction maneuver