Children and Nursemaid's Elbow

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I never knew how fragile a child's joints are until the day after New Year's day. I was in the living room playing with my son. He started screaming. I did not know what was wrong. All I knew is he was screaming and his right arm was not moving. As fast as possible, I took him to the ER. Apparently he had rolled over in an odd way onto his arm causing the elbow to dislocate. I now know that this sort of injury can occur many different ways. Until then, I thought that joints dislocated when substantial amount of force is used. A child under the age of 4 can dislocate his or her arm by simply pulling away from his or her parent. I urge all parents to find other ways of leading their young children. If all else fails, simple pick up your child. 

Facts about Nursemaid's elbow from http://pedclerk.bsd.uchicago.edu/nursemaidElbow.html

Nursemaid's Elbow

Nursemaid's elbow is a common injury that is seen most often in children between the ages of 1-3 years . Usually the child has had an incident in which the extended arm was pulled. Most commonly it occurs when a child is falling and the individual holding the hand doesn't let go. Another common mechanism is when the child is swinging while being held by the hands. Occasionally, the injury occurs after a fall. 

Anatomy

Nursemaids elbow is an interposition of the annular ligament into the radial-humerus joint. The annular ligament normally passes around the proximal radius just below the radial head. With traction on the extended arm, the annular ligament slides over the head of the radius into the joint space and becomes entrapped. 

Epidemiology

1. Nursemaid's elbow is more common in girls than boys and more often on the left side.
2. Usually between 1-3 years of age and rare after age 4.

Clinical presentation

1. There is usually a history of axial traction. 
2. have been reports of infants < 6 months old with a history of not using arm after rolling over and their arms getting caught.
3. At times, there is no history of axial traction or none was observed.
4. Child will not use the arm and holds the arm slightly flexed and pronated.
5. May elicit tenderness over the elbow joint but there is no swelling, redness, warmth, abrasions, or ecchymosis.

Diagnosis

1. The diagnosis is by history and physical examination. Radiograph examination is usually not necessary and are normal in most instances. Often during the taking of the xray, the subluxation is reduced when the technician positions the aarm on the plate.

Treatment

1. While supporting the radial head, the forearm is supinated or pronated and flexed at the same time. A "click" will be heard or felt. 
2. After the "reduction", the child will immediately use the arm. There is no indication for immobilization and rarely are analgesics necessary. 
3. Unless the child doesn't start to use the arm, follow-up is unnecessary.
4. There is a relatively high incidence of recurrence. Parents should be made aware of this and the mechanism of injury should be explained. It may be useful to teach the parents how to "reduce" the dislocation at home. 
5. There are no known sequelae.

References

1. Choung, Walter, and Heinrich,Stephen. Acute Annunlar Ligament Interposition into the Radiocapitellar Joint in Children (Nursemaid's Elbow). Journal ofPediatric Orthopedics. Vol. 15, No.4 1995
2. Waander, Hellerstein, and Ballock. Nursemaid's Elbow, Pulling out the Diagnosis  Contemporary Pediatrics June 2000

Nursemaid's elbow
The normally effects children

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