How to diagnose and reduce a nursemaid’s elbow

Siamak Moayedi, MD
19th Nov 2020

What is a nursemaid’s elbow?

The correct medical term for a nursemaid’s elbow is radial head subluxation. Essentially, the annular ligament that holds the radial head slips and gets trapped in the elbow joint.

This is a common pediatric issue that typically happens to kids between the ages of one and three, but it can happen to kids as old as six.

Front view of elbow with labels on the humerus, annular ligament, radius, and ulna. Illustration.

Figure 1. Anatomy of the elbow joint. 

 

What causes nursemaid’s elbow?

The classic story for a nursemaid’s elbow is a toddler running into the street, and the adult yanking them back. This causes longitudinal traction of the arm with the wrist in pronation, which leads to the annular ligament slipping from around the radial head. As a result, part of the ligament gets trapped between the capitulum (end of the humerus) and the radial head. 

 

How to diagnose nursemaid's elbow

Physical signs of nursemaid's elbow

The child will not be in any pain but will refuse to use the affected arm and will hold it slightly flexed with the wrist pronated. This posture will prompt parental concern. 

Child with elbow flexed and their wrist pronated. Cartoon.

Figure 2. A child with nursemaid's elbow tends to hold their arm with the elbow flexed and the wrist pronated.

It is important to make sure there is no other injury, such as a fracture of the clavicle, humerus, radius, or ulna. Be sure to palpate these areas. 

Always consider child abuse in cases of nursemaid’s elbow. An isolated nursemaid’s elbow can happen with a fall or rolling over in bed, so it doesn’t necessarily imply child abuse. But, it is important to keep the possibility in mind.

 

Diagnostic tests for nursemaid's elbow

If the child is cooperative and there is no pain with palpation of the arm, it’s perfectly reasonable to attempt to reduce the dislocation without an x-ray.  

If you’re unsure, or there is evidence of trauma (e.g., pain, bruising, or swelling) you should get an x-ray. Now, a nursemaid’s elbow without evidence of trauma will appear normal on an x-ray. So, you must look for physical signs of a nursemaid’s elbow instead of relying on an x-ray to confirm your diagnosis.

 

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Procedure for reducing a nursemaid’s elbow

The good news is that a nursemaid’s elbow is easy to fix! You won’t need any sedation or medication. Explain to the parent that once you reduce the radial head, their child will start to cry, mainly because they are startled. To begin, have the patient sit in their parent’s lap.

  1. With the palm facing down, grasp the elbow with your thumb over the radial head. With your other hand, grasp the child’s wrist. 
  2. Supinate the extended forearm.
  3. Apply traction to the forearm. 
  4. Immediately flex the elbow. You will feel a click with your thumb that was over the radial head.

Multi-component image of clinician grasping the elbow and wrist of patient, supinating the extended forearm, applying traction, and flexing the elbow. Cartoon.

Figure 3. Procedure for reducing a nursemaid’s elbow. 1) Grasp the wrist and elbow with your thumb over the radial head. 2) Supinate the extended forearm. 3) Apply traction. 4) Immediately flex the elbow.  

The child will immediately start to cry, mainly because they are startled. Leave the room to give the child a few minutes alone with their parents to recover. After a few minutes, the child will be happy and back to using the arm normally. 

This is a favorite quick procedure amongst emergency room doctors. The parents come in worried and are so relieved when they see their child using their arm again. Be sure to talk to the parents about not picking their child up by the arm, if they can help it.

 

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Recommended reading

  • Roberts, J. 2019. “Management of common dislocations”. In: Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th edition. Philadelphia: Elsevier.