Pulled Elbow (Nursemaid's Elbow): Symptoms, Professional Relocation, and Prevention

How do you relocate a pulled elbow?

Relocating a pulled elbow, also known as Nursemaid's elbow or radial head subluxation, is a precise medical procedure that should only be performed by a trained healthcare professional to ensure proper diagnosis and prevent further injury.

Understanding a Pulled Elbow (Nursemaid's Elbow)

A pulled elbow, clinically termed radial head subluxation, is a common injury in young children, typically between 1 and 4 years old. It occurs when the radial head (the top part of the forearm bone, the radius) slips out from under the annular ligament that holds it in place around the humerus (upper arm bone).

• Mechanism of Injury: This injury most frequently results from a sudden, forceful pull on an extended arm. Common scenarios include:
  • Pulling a child up by their hands or wrists.
  • Swinging a child by their arms.
  • A child falling awkwardly while holding an adult's hand.
• Anatomy Involved: The elbow joint is a complex hinge joint. The key structures involved in a pulled elbow are:
  • Radius: The forearm bone on the thumb side.
  • Annular Ligament: A strong band of connective tissue that encircles the radial head, holding it against the ulna (the other forearm bone) and humerus. In young children, this ligament is looser and the radial head is smaller, making it more susceptible to slipping out.
• Symptoms: A child with a pulled elbow will typically:
  • Refuse to use the affected arm.
  • Hold the arm close to the body, often slightly bent at the elbow, with the palm turned inward (pronated).
  • Show pain when the arm is moved, but usually not severe pain at rest.
  • Lack visible swelling or deformity, which can make diagnosis challenging for an untrained eye.

Why Self-Relocation is NOT Recommended

Attempting to relocate a pulled elbow without medical training carries significant risks and is strongly discouraged.

• Risk of Misdiagnosis: The symptoms of a pulled elbow can mimic other, more serious injuries, such as a fracture (broken bone) or a more complex dislocation. An X-ray might be necessary to rule out a fracture, especially if the mechanism of injury is unclear or if the child is older. Manipulating a fractured arm could cause severe pain and further damage.
• Risk of Improper Technique: The delicate structures of a child's elbow are vulnerable. Incorrect manipulation can:
  • Cause additional soft tissue damage to ligaments, tendons, or nerves.
  • Lead to a more complex dislocation.
  • Increase the child's pain and distress.
  • Make subsequent professional relocation more difficult.
• Importance of Medical Expertise: Healthcare professionals are trained to:
  • Accurately diagnose the injury.
  • Rule out other conditions.
  • Perform the relocation maneuver safely and effectively, minimizing trauma and pain for the child.

The Relocation Procedure (Performed by a Medical Professional)

When a child presents with a suspected pulled elbow, a medical professional will follow a structured approach to confirm the diagnosis and perform the reduction.

• Initial Assessment:
  • History Taking: Understanding how the injury occurred is crucial.
  • Physical Examination: Gently assessing the arm for pain, range of motion, and ruling out other injuries. X-rays may be ordered if a fracture is suspected.
• Two Primary Relocation Techniques: Both methods aim to gently guide the radial head back into its correct anatomical position under the annular ligament. The physician will choose the method based on preference and the child's presentation.
  • Supination-Flexion Method: This is a commonly used technique.
    • The physician holds the child's wrist with one hand and places the thumb of the other hand over the radial head (just below the elbow joint).
    • The forearm is gently supinated (rotated so the palm faces upward).
    • While maintaining supination, the elbow is then slowly and fully flexed (bent) towards the shoulder.
    • Gentle pressure may be applied over the radial head during this movement.
  • Hyperpronation Method: This technique is often equally or more effective and may be preferred by some clinicians.
    • The physician holds the child's wrist with one hand and places the thumb of the other hand over the radial head.
    • The forearm is gently but firmly hyperpronated (rotated so the palm faces downward, past the neutral position).
    • This movement alone is often sufficient to relocate the radial head.
• Key Principles of Relocation:
  • Gentle and Controlled: The movements are smooth, not forceful.
  • No Distraction: The arm is not pulled during the procedure, as this could worsen the injury.
  • Reassurance: The professional will aim to keep the child calm and comfortable throughout.
• Signs of Successful Relocation:
  • A subtle "click" or "pop" may be felt or heard as the radial head slips back into place.
  • Almost immediate relief of pain for the child.
  • The child will typically begin to use their arm normally within minutes, often reaching for a toy or moving their arm spontaneously.

What to Do If You Suspect a Pulled Elbow

If you believe a child has a pulled elbow, follow these steps immediately:

• Remain Calm: Your calm demeanor will help reassure the child.
• Avoid Manipulation: Do not attempt to pull, twist, or straighten the child's arm yourself. This can cause more pain and damage.
• Support the Arm: Gently support the injured arm in a comfortable position, often by holding it close to the child's body or using a makeshift sling if available. The goal is to keep the arm still and prevent further movement.
• Seek Immediate Medical Attention: Take the child to an urgent care clinic, emergency room, or their pediatrician as soon as possible. Prompt medical attention leads to a quick and effective resolution.

Prevention Strategies

Preventing pulled elbows involves mindful handling of young children:

• Avoid Lifting by Hands or Wrists: Always lift children by supporting their torso, under their armpits, or by their hips.
• Be Cautious During Play: Refrain from swinging children by their arms or hands.
• Educate Caregivers: Ensure anyone caring for your child understands the risks and proper handling techniques.
• Supervise Active Play: While accidents can happen, supervision helps prevent situations where a child might fall and have their arm suddenly pulled.

Recovery and Prognosis

Once a pulled elbow has been successfully relocated by a medical professional, the recovery is typically rapid and complete.

• Immediate Improvement: Most children will start using their arm normally almost immediately after the procedure.
• No Ongoing Treatment: Usually, no further treatment, casting, or physical therapy is required.
• Risk of Recurrence: Children who have experienced a pulled elbow once are at a slightly higher risk of it happening again, particularly within the first few months. This is due to the inherent laxity of the annular ligament in young children.
• Long-Term Outlook: The long-term prognosis for a pulled elbow is excellent. The annular ligament strengthens as the child grows, and by around age 5 or 6, the risk of recurrence significantly diminishes.