Milkmaid's Elbow (Nursemaid's Elbow): Symptoms, Treatment, and Prevention

How do you treat milkmaid's elbow?

Milkmaid's elbow, clinically known as radial head subluxation or nursemaid's elbow, is primarily treated through a quick, manual reduction maneuver performed by a trained healthcare professional to gently guide the radial head back into its correct anatomical position.

Understanding Milkmaid's Elbow (Nursemaid's Elbow)

Milkmaid's elbow is a common musculoskeletal injury in young children, typically between 1 and 4 years of age, though it can occur up to age 6 or 7. It results from a sudden pull or traction force on the child's arm, causing the head of the radius bone to slip partially out from under the annular ligament that holds it in place at the elbow joint. This often happens when a child is lifted by one hand, swung by the arms, or falls with an outstretched arm while being held. The term "milkmaid's elbow" is an older, less common name for what is more widely known as "nursemaid's elbow."

Recognizing the Symptoms

The hallmark signs of milkmaid's elbow are usually immediate and distinct:

• Sudden onset of pain in the elbow or arm.
• Refusal to use the affected arm, often holding it still at their side, typically with the elbow slightly bent (flexed) and the palm turned inward (pronated).
• Lack of visible deformity, swelling, or bruising around the elbow.
• Crying or distress due to the pain, which often subsides once the arm is still.
• Pain with attempted movement of the elbow or arm, especially supination (turning the palm upward).

It's crucial to note that while the child is in pain, there is no fracture or dislocation in the traditional sense, which is why the appearance of the elbow remains normal.

Immediate Actions and When to Seek Professional Help

If you suspect milkmaid's elbow, the most important immediate action is to:

• Do NOT attempt to "pop" the elbow back into place yourself. This can cause further injury or distress.
• Keep the child calm and comfortable. Avoid moving the affected arm.
• Seek immediate medical attention. This condition requires a healthcare professional (e.g., pediatrician, emergency room physician, orthopedic specialist) to perform the reduction.

Prompt treatment is important not only for pain relief but also to prevent the child from developing a habit of not using the arm, which could lead to secondary issues.

The Definitive Treatment: Manual Reduction

The treatment for milkmaid's elbow is a specific, gentle manual procedure performed by a trained medical professional. This procedure is known as reduction. There are two primary techniques commonly used:

• Supination-Flexion Method:
  • The healthcare provider supports the child's elbow with one hand.
  • The forearm is then gently but firmly supinated (turned palm upward).
  • While maintaining supination, the elbow is slowly and fully flexed (bent) towards the shoulder.
  • A subtle "click" or "pop" may be felt or heard as the radial head slips back into place.
• Hyperpronation Method:
  • The healthcare provider supports the child's elbow.
  • The forearm is then gently but firmly hyperpronated (turned palm downward even further than normal).
  • This maneuver often achieves reduction without the need for additional flexion.
  • Again, a "click" or "pop" may indicate successful reduction.

Both techniques are highly effective, with success rates often exceeding 90%. The procedure is usually very quick, often taking only a few seconds. While the child may experience momentary discomfort during the reduction, relief is typically immediate upon successful repositioning of the radial head.

Post-Reduction Care and Recovery

Following a successful reduction:

• Immediate Use of the Arm: The most reliable sign of successful reduction is the child's willingness to immediately begin using the arm. Often, within minutes, the child will start moving the arm, reaching for toys, or clapping.
• No Immobilization: Unlike fractures or severe dislocations, milkmaid's elbow typically does not require casting, splinting, or slings after reduction. The annular ligament usually holds the radial head securely once it's back in place.
• Observation: Parents are advised to observe the child for the next few hours to ensure full return of function.
• Activity Modification: While immediate use is expected, it's prudent to advise avoiding strong pulling or lifting by the affected arm for a few days to a week to allow any minor ligamentous irritation to settle.
• Pain Management: Over-the-counter pain relievers (e.g., ibuprofen, acetaminophen) may be used if the child experiences any residual soreness, though this is uncommon once the elbow is reduced.

Preventing Recurrence

While a single episode of milkmaid's elbow is common, some children may be prone to recurrence, especially if the precipitating activities continue. Prevention strategies focus on educating parents and caregivers:

• Avoid lifting or swinging a child by their hands or wrists. Always lift a child by holding them under the arms or around the torso.
• Do not pull a child by one arm when helping them up stairs, over curbs, or through crowded areas.
• Be cautious when dressing a child, avoiding forceful pulling of sleeves over the hands.
• Educate other caregivers (grandparents, babysitters) about the risk and preventive measures.

When to Consult a Specialist

While most cases are straightforward, there are instances where further medical consultation may be warranted:

• Repeated Occurrences: If a child experiences recurrent episodes, an orthopedic specialist may be consulted to rule out any underlying ligamentous laxity or other anatomical predispositions.
• Persistent Pain or Refusal to Use Arm After Reduction: If the child does not immediately begin using the arm after a reduction maneuver, or if pain persists, it could indicate an unsuccessful reduction, a different injury (e.g., fracture), or a more complex issue. Further imaging (X-ray) or referral may be necessary.
• Unusual Mechanism of Injury: If the injury occurred due to a significant fall or direct trauma, other injuries should be considered and evaluated.

Understanding the mechanics of milkmaid's elbow and the appropriate treatment protocols ensures prompt relief and prevents unnecessary complications, allowing the child to quickly return to normal activity.