A healthy 2-year-old female is brought to the emergency department because she is not using her left arm. The patient was holding her father’s hand while walking when she tripped. To prevent her from falling, her father held onto the patient’s left hand and pulled her up as she tripped. The patient cried immediately and then she calmed. She did not seem to be in pain, but she would not move or use her left arm. She held her left arm close to her side with her elbow slightly bent and her palm turned toward her body (Figure 82-1). Father denies bruising, swelling, fevers, other injury, or recent illnesses. She was diagnosed with nursemaid’s elbow, which was successfully reduced in the emergency department and she regained full use of her arm immediately.
Typical posture of a child with nursemaid’s elbow. Note how the affected left arm is held next to the body with the elbow slightly bent and the forearm pronated. (Used with permission from Paula Sabella, MD.)
Nursemaid’s elbow is a very common injury in preschool aged children. It usually results from a pull to the arm or wrist of a child causing displacement of the annular ligament of the elbow and subluxation of the radial head. This results in pain and refusal to use the arm. The child classically holds the affected elbow close to the body and mildly flexed with pronation of the forearm. The diagnosis is made clinically. The radial head subluxation is usually able to be quickly and easily reduced in the office or emergency department.
Radial head subluxation; temper tantrum elbow; annular ligament displacement; pulled elbow.
Occurs in children aged 6 months to 5 years, with the peak incidence between 2 and 3 years of age.1–4
Left elbow is most commonly affected.2,4
Affects girls more than boys.1,2,4
Etiology and Pathophysiology
The classic mechanism of injury in nursemaid’s elbow involves axial traction to a child’s pronated forearm or upper extremity.2 This usually involves a pulling or tugging motion to the upper extremity.
When the radius is pulled distally, part of the annular ligament shifts proximally over the radial head and becomes caught in the radiohumeral joint (Figure 82-2).2,3 This causes pain and refusal to use the affected arm.
In many cases of nursemaid’s elbow, the typical history of a pulling type of injury is not reported.5
Examples of mechanisms reported in patients with nursemaid’s elbow include:1,2,5