Overview

Nursemaid’s elbow is a common childhood injury, especially under the age of seven years.¹ It is more commonly known as a ‘slipped’ or ‘pulled elbow’, as it is caused by any pulling motion that leads to the dislocation of a bone within the elbow joint. Nursemaid’s elbow results in partial dislocation of the elbow, as the annular ligament slips out of place. In this article, we will discuss the causes, diagnosis, and treatment of nursemaid’s elbow in further detail.

What are the causes of nursemaid’s elbow?

The phrase ‘nursemaid’s elbow’ is derived from when a child’s nanny was blamed for causing the injury to children’s arms due to pulling when taking care of them.² The medical term is ‘radial head subluxation’ or ‘annular ligament displacement’. Nursemaid’s elbow is more commonly referred to as a ‘pulled elbow’ due to the dislocation of the annular ligament. This means that the joints within the elbow are pulled apart, allowing the two forearm bones, called the radius and the ulna, to abnormally touch. As a result, flexible movement of the elbow is no longer possible.² 

The annular ligament is made of elastic tissue to support the bones within the elbow region. When the ligament is slipped out of place, this causes the support that holds the bones in place to fade. This is because the ligament has glided off from the bone, and thus it is not in its proper place. Over time, this can cause swelling due to the joints rubbing against one another.² 

Nursemaid’s elbow frequently occurs in children under the age of 7, especially between the ages of 1 and 4.^3,4 It is also more common for children assigned female at birth (AFAB) to have nursemaid's elbow.⁴ Children are more likely to get a nursemaid’s elbow as their bones and ligaments are still developing and are fairly loose. This means they can easily glide off whenever a pulling force is applied to the arm or hand.²

Common causes of nursemaid’s elbow include:^2,3

• Pulling a child up by their hands, wrists, or arms
• Holding the child by the hand while walking
• Suddenly tugging, pulling or jerking a child’s arm, especially when a child is resisting or going in a different direction (e.g., pulling a child’s arm to prevent a fall)
• Pulling a child’s arm through a coat sleeve with too much force
• Swinging a child around or back and forth by their hands or arms during play

It is worth mentioning that nursemaid’s elbow could be caused by falls but this is rarely the case.

Symptoms of nursemaid’s elbow

Symptoms of nursemaid’s elbow include:^5,6

• Experiencing extreme pain during the partial dislocation
• Crying due to the initial pain caused by the injured arm
• The injured arm is slightly flexed abnormally at the elbow
• Limited motion of the injured arm 
• Children might keep the injured arm on their lap or by the side of their body to avoid using the arm
• Children will try to use the opposite hand to support the injured elbow
• No obvious swelling

In addition, nursemaid’s elbow is often characterised by a history of pulling-type injury. As well as by the feeling or sound of a ‘pop’ from the joint and ligaments being partially displaced.²

If a child is experiencing any of these symptoms, seek medical attention immediately. It is important to make sure not to try to straighten the arm or move the elbow back into place yourself as this could cause more damage.

Diagnosis of nursemaid’s elbow

Diagnosis normally involves a physical examination and history check conducted by a medical professional.⁴ Diagnosis via radiography or X-rays is not necessary for a pulled elbow. However, they may be used to ensure that the injury is not extremely serious, such as a severe elbow fracture. This is especially important for children who continue to experience:²

• Prolonged feeling of discomfort and pain
• Increased swelling from the injured arm
• Deformity in the bone
• Any cut in the skin close to the elbow

Your child must be evaluated by a medical professional, who can make an effective diagnosis and treatment plan for your child.

Treatment of nursemaid’s elbow

As mentioned previously, it is hard to know how severe the elbow injury is. Generally, it is easier to treat and manage nursemaid’s elbow compared to a severe elbow fracture. The reduction method is used to treat nursemaid's elbow.

What is the reduction method?

The reduction method involves the use of a simple manipulation of the elbow. It involves the following steps:^3,6

1. The child sits on the parent's or caregiver’s lap
2. The medical professional quickly but gently moves the joint back into place. The two most common ways are:
   • Supination-flexion involves the outward rotation of the forearm followed by elbow flexion (or in other words moving the elbow)
   • Hyperpronation is where the forearm is rotated inwards while the child’s thumb is pointing downwards. This type of reduction is more effective than the supination-flexion method
3. A small ‘pop’ or ‘click’ may be heard when the joint slips into place
4. The child is monitored after to check that they can use the treated arm normally

This process is effective because it is easy to treat in a matter of seconds. It almost immediately eliminates pain while causing no permanent damage. Most children are able to use their treated arm approximately 30 minutes after undergoing the reduction method.

Occasionally, the steps within the reduction method are attempted again if there is no success in placing the joints back in their original state properly.¹ Afterwards, the child will be monitored until normal function of the arm is resumed. If the child continues to feel discomfort, paracetamol could be used.² No follow-up is necessary after treatment, however, ibuprofen can be used as an anti-inflammatory should the child still feel pain.³

Risks of nursemaid’s elbow

The longer it takes for a child to be seen by a medical professional, the longer it will take for the child’s arm to return to normal function.³ Prolonged neglect may also cause permanent functional disability of the elbow.⁷ However, it is beneficial to know that as children continue to develop and grow, their bones and ligaments are strengthened. Thus, reducing the risk of having or experiencing nursemaid’s elbow again.

Prevention of nursemaid’s elbow

Several strategies can be implemented to prevent nursemaid’s elbow:²

• Avoid abruptly pulling a child by their hands, wrists, or arms
• Avoid swinging a child around or back and forth by their hands or arms during play
• Avoid abruptly tugging or pulling a child’s arm, especially when a child is resisting and pulling in the opposite direction
• Avoid pulling a child’s arm through a coat sleeve with too much force
• Always try to lift children by their armpits instead of by their hands or wrists

Some children have very loose joints and ligaments, so there is an increased risk of nursemaid’s elbow occurring frequently.⁸ Therefore, it is best to seek further advice from medical professionals on how to prevent this.²

Summary

As children get older, their bones, joints, and ligaments develop and grow. Nursemaid’s elbow is generally caused by sudden pulling, jerking, or tugging of the arm, which causes a partial dislocation of the bones and ligaments within the elbow joint. The main symptom of nursemaid’s elbow is limited motion of the injured arm. It is important to seek medical attention to enable early diagnosis and treatment.

Neglecting to seek professional help could lead to further problems, such as a severe elbow fracture or permanent functional disability of the elbow. Reoccurrence of nursemaid’s elbow is possible for children, so parents should seek advice from medical professionals on how to prevent this from happening frequently. It is important to note that the likelihood of having a nursemaid's elbow reduces as children’s bones, joints, and ligaments strengthen over time as their bodies continue to develop.