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Symptoms and Signs of Nursemaid's Elbow in Children

Doctor's Notes on Nursemaid Elbow in Children Symptoms, Signs, and Reduction Pain

Nursemaid elbow (radial head subluxation) is a common injury among preschool-aged children in which the normal anatomical alignment of two of the three bones that form the elbow joint is disrupted. It takes very little force to pull the bones of a young child's elbow out of place and nursemaid elbow may occur simply by swinging a young child by the arms or pulling a child's arm while in a hurry.

Symptoms of nursemaid elbow include crying from pain immediately after the injury, refusal to use the involved arm, holding the arm protected against the body slightly bent with the forearm turned with the thumb toward the body, and supporting the painful arm with the other hand. Shortly after the acute injury the child will usually calm down and may return to activities but will refuse to use the affected arm. Children old enough to talk may describe pain in the wrist or shoulder in addition to, or in place of, pain in the elbow.

Medical Author: John P. Cunha, DO, FACOEP
Medically Reviewed on 3/11/2019

Nursemaid Elbow in Children Symptoms, Signs, and Reduction Pain Symptoms

Immediately after the injury occurs, the child generally cries in pain and will refuse to use the involved arm. Typically, the arm will be protected against the body and held slightly bent (in flexion) with the forearm turned with the thumb toward the body (in pronation). The child will often support the painful arm with their other hand. The child will usually be calm shortly after the initial event and may return to playing only now without the use of the affected arm. When the forearm is turned with the thumb away from the body to show the palm upward (in supination), the child will resist and cry in pain. A child who is old enough to talk may often describe pain in the wrist or shoulder in addition to, or in place of, any pain in the elbow. Most commonly, your child will appear completely unchanged with the exception that he or she will no longer use the injured arm.

Nursemaid Elbow in Children Symptoms, Signs, and Reduction Pain Causes

Nursemaid elbow results from a sudden pulling force applied to the extended arm of a child. Due to the relative strength of the adult in comparison to the weakness of the child's supportive annular ligament, the applied force may not seem strong to the parents and they may not realize an injury has occurred.

Examples of typical situations that can produce the mechanism of force required to cause this injury are lifting the child up from the ground by the hand or wrist, swinging the child while holding the child by the hands or wrists, pulling arms through the sleeves of jackets, catching a child by the hand to prevent a fall, and pulling a child along when in a hurry or the child suddenly collapsing to the ground in an effort to avoid going with their parent.

The young child is prone to this type of injury largely because of the anatomical features of their bones and ligaments. Understanding the mechanism of this injury is helpful in explaining the cause.

  • The end of the radius that connects to the elbow joint is known as the radial head. The radial head has a shallow concave shape allowing it to fit over a complementary convex prominence at the end of humerus (the capitellum). As the child matures, the radial head broadens and ultimately becomes wider than the portion of the radius (called the radial neck) adjacent to the head. In the young child, the radial head does not yet have a well-defined lip at its end. As such, in the toddler, the radial neck and radial head are similar in size.
  • The annular ligament holds the radius alongside the ulna, which is the other bone in the forearm. Besides stabilizing the radial head-humerus joint, the annular ligament permits the radius to twist when the hand changes position from palm down (prone) to palm up (supine). In young childhood, the annular ligament is still relatively loosely attached to the bone and can experience a small tear in some of its fibers.
  • The combination of these two things (shallow concave radial head and loose-fitting annular ligament which may easily partially tear) allows the loose portions of the ligament to slide over the radial head when a pulling force is applied to the elbow while the forearm is slightly rotated palm down (pronation). When this happens, this annular ligament tissue can become trapped between the radial head and the capitellum, resulting in the subluxation of the radial head, or nursemaid elbow.

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Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.