Nursemaid's Elbow: Understanding, Professional Reduction, and Prevention

How to reduce a pulled elbow?

Reducing a pulled elbow, medically known as radial head subluxation or nursemaid's elbow, is a specific maneuver that should only be performed by a trained healthcare professional, such as a physician or urgent care specialist, due to the risk of misdiagnosis or improper technique leading to further injury.

Understanding a Pulled Elbow (Nursemaid's Elbow)

A pulled elbow, or nursemaid's elbow, is a common injury in young children, typically between the ages of 1 and 4. It occurs when the radial head, one of the bones of the forearm, partially slips out from under the annular ligament that holds it in place around the elbow joint.

• Mechanism of Injury: This injury most frequently happens when there is a sudden pull or tug on a child's outstretched arm. Common scenarios include:
  • Lifting a child by one hand or wrist.
  • Pulling a child up a step or over an obstacle.
  • Swinging a child by their arms.
  • A child falling onto an outstretched arm (less common).
• Anatomy Involved: The elbow joint is formed by the humerus (upper arm bone) and the radius and ulna (forearm bones). The radial head is the top part of the radius, which articulates with the humerus and is stabilized by the annular ligament. In young children, this ligament is relatively loose, making them susceptible to this subluxation.
• Symptoms: The primary symptom is sudden pain in the elbow, often leading to the child refusing to use the affected arm. They may hold the arm limp at their side, slightly bent, and rotated inward. There is usually no swelling or deformity, and the child may not cry continuously but will resist any attempt to move the arm.

Why You Should NOT Self-Reduce a Pulled Elbow

While the reduction maneuver for a pulled elbow appears simple, attempting to self-reduce it carries significant risks and is strongly discouraged for several critical reasons:

• Risk of Misdiagnosis: The symptoms of a pulled elbow can mimic other, more serious injuries, such as a fracture or dislocation. Without a proper medical assessment, you could be attempting to reduce a bone that is actually broken, causing severe pain and further damage.
• Improper Technique: Even if it is a true nursemaid's elbow, an incorrect reduction technique can cause more pain, fail to reduce the joint, or even damage the ligament or growth plate.
• Increased Pain and Trauma: An untrained attempt at reduction is likely to cause the child unnecessary pain and distress, making future medical examinations more challenging.
• Professional Expertise: Healthcare professionals are trained to correctly diagnose the injury, rule out other conditions, and perform the reduction efficiently and safely, minimizing discomfort for the child.

The Professional Reduction Process

When a child with a pulled elbow is brought to a healthcare provider, the diagnosis is typically made based on the history of injury and a physical examination. X-rays are usually not needed unless a fracture is suspected. The professional will then perform one of two common reduction techniques:

• Supination-Flexion Method:
  1. The healthcare provider will gently grasp the child's hand.
  2. The forearm is then supinated (rotated so the palm faces upward).
  3. While maintaining supination, the elbow is gently but firmly flexed (bent) towards the shoulder.
  4. A subtle "click" or "pop" may be felt or heard as the radial head slips back into place.
• Pronation Method:
  1. The healthcare provider will support the child's elbow with one hand.
  2. The forearm is then gently but firmly pronated (rotated so the palm faces downward).
  3. Similar to the supination-flexion method, a click or pop may indicate successful reduction.

Both methods are highly effective. The choice of method often depends on the practitioner's preference and the child's presentation. After successful reduction, the child typically experiences immediate relief and starts using their arm within minutes, sometimes within seconds.

Post-Reduction Care and Recovery

Following a successful reduction, the child's recovery is usually swift and complete.

• Immediate Relief: The most striking aspect of a pulled elbow reduction is the almost instantaneous relief of pain and the immediate return of function. Within minutes, the child will often begin to move their arm normally, reaching for toys or objects.
• Activity Restrictions: While immediate use is common, it's advisable to avoid vigorous pulling or tugging on the affected arm for at least a few days to allow the annular ligament to settle. Normal play activities are generally fine.
• Follow-up: A follow-up visit is typically not required unless there are concerns about the child's continued use of the arm or if the injury recurs.

Preventing Future Pulled Elbow Incidents

Prevention is key, especially since some children may be prone to recurrent pulled elbows. Educating caregivers on safe handling practices is crucial.

• Avoid Lifting by the Hands/Wrists: Never lift a child by their hands, wrists, or forearms. Always lift them by grasping under their armpits or around their torso.
• No Swinging by Arms: Refrain from swinging children by their arms, even playfully. This is a common cause of the injury.
• Safe Handling During Play: When helping a child up a step or over an obstacle, support them by their trunk or upper arms, not their hands.
• Be Mindful of Sudden Pulls: Be aware of situations where a child might suddenly pull away or be pulled inadvertently. For example, when holding hands, be prepared to release if the child trips or pulls back forcefully.

When to Seek Medical Attention

While a pulled elbow is generally not serious and resolves quickly with professional reduction, it's important to know when further medical attention is warranted:

• Inability to Move Arm After Reduction: If the child does not regain full use of their arm within 15-30 minutes of a professional reduction, it could indicate an incomplete reduction, a different underlying injury (like a fracture), or that the radial head has slipped out again.
• Persistent Pain or Swelling: While pain should resolve quickly, any persistent pain, swelling, or visible deformity warrants immediate re-evaluation.
• Recurrent Episodes: If a child frequently experiences pulled elbows, a healthcare provider may offer additional advice on prevention or explore if there are any underlying factors contributing to the recurrence.
• Other Concerns: Always seek medical attention if you have any doubts about the nature of the injury or the child's recovery.

Understanding the mechanism and proper treatment of a pulled elbow empowers caregivers to ensure their child receives appropriate and timely care, minimizing discomfort and facilitating a swift return to normal activity.