View Entire Collection
By Clinical Topic
Diabetes – Summer 2012
Future of Nursing Initiative
Heart Failure - Fall 2011
Influenza - Winter 2011
Nursing Ethics - Fall 2011
Trauma - Fall 2010
Traumatic Brain Injury - Fall 2010
Fluids & Electrolytes
Pediatric trauma injuries account for 11 million hospitalizations annually with a significant percentage related to the musculoskeletal system. Nursemaid's elbow is a common injury in young children that can often be prevented. This injury occurs when the radial head subluxates from its normal position at the elbow joint. Activities such as swinging a child by the hands or pulling on the pronated upper extremity can cause nursemaid's elbow. Prevention of nursemaid's elbow in children may be accomplished with education of parents, daycare workers, and teachers on the mechanism of this common injury.
Pediatric trauma injuries account for 11 million hospitalizations annually (Vitale & Mooney, 2005), with a significant percentage related to the musculoskeletal system. Injuries to the elbow in the pediatric population are common and may be related to a fracture, dislocation, or subluxation. Fractures are usually caused by a direct force to the bony structures of the elbow. A dislocation of the elbow represents the most common joint dislocation in children and is often associated with a fracture. A subluxation of the elbow in a child, commonly referred to as nursemaid's elbow, is a common problem in children aged 2 through 5 (Kunkler, 2000). One 1995 study reported that of children younger than 6 years of age presenting to an urban pediatric emergency department with a chief complaint of upper extremity injury or immobility, 63% had a final diagnosis of radial head subluxation (Schultzman & Teach, 1995). The mechanism of injury is usually a forceful tug or pull on an extended, pronated upper extremity. The terms "pulled elbow" or "radial head subluxation" are also used to identify this type of injury. Although the term "nursemaid's elbow" does not accurately describe the injury itself, it describes that in most cases, the caregiver (parent, sibling, day care provider, or teacher) inadvertently injures the child while holding or pulling on the upper extremity.
The elbow joint is a hinged joint composed of bones, ligaments, muscles, nerves, and blood vessels (see Figure 1). The annular ligament is a band of fibrous tissue that provides support to the radial head as the forearm supinates and pronates. Typically, the radial head subluxates following a strong pull on the elbow joint, resulting in the stretch of the annular ligament. This ligament is not as strong in a child, and this is why the subluxation occurs significantly more often in children than in adults. Once the annular ligament is stretched and(or torn, it allows the head of the radius to be displaced. The annular ligament can then slip between the radius and the capitellum, preventing spontaneous reduction of the subluxation.
The medical history surrounding the onset of the injury often quickly allows the healthcare provider to determine the type of injury. Common precipitators of a pediatric radial head subluxation are (1) pulling on the child's arm while leading the child in one direction (see Figure 2), (2) helping the child up a curb or stairs, or (3) a child falling or suddenly deciding to drop to the ground when the adult is holding the hand. In addition, the seemingly innocuous activity of holding the child's hand and twirling the child in the air is often the cause of this injury (see Figure 3). Nursemaid's elbow has even been reported to occur in infants who have rolled over to change positions.
Without a clear description of an event that would commonly cause subluxation of the radial head, the child should be evaluated to rule out a fracture or dislocation. The physical examination consists of examining the upper extremity for deformity, swelling, intact skin, and neurovascular status. Radiology evaluation should be undertaken if there are indications that a fracture might be present and in cases where the mechanism of injury is not clear. Anterior-posterior and lateral radiographs of the elbow should then be obtained prior to reduction of the injury.
Hart, Grottkau, Rebello, and Albright (2006) discuss the difficulty in the interpretation of radiographic examinations in the pediatric age group because the skeletally immature pediatric elbow mostly consists of cartilage. Normal ossification centers can often be confused with fractures in this age group. Astute radiographic interpretation, combined with the history of the incident, clinical presentation, and examination/ findings, will usually confirm the diagnosis.
The common symptoms of a subluxation of the elbow in a child include pain as evidenced by crying, holding of the arm in a slightly flexed position against the side of the body or across the stomach, and refusing to use the arm for any activity. The child is often irritable and may be anxious. Depending on the age of the child, he/she might experience a popping sound or feeling just prior to the onset of the pain. In most cases, swelling and ecchymosis will not be present (Waanders, Hellerstein, & Ballock, 2000), which helps providers differentiate nursemaid's elbow from acute fractures.
A nursemaid's elbow can be effectively treated with rapid relocation of the subluxed radial head. Confirmation that the injury is a nursemaid's elbow and not a fracture allows the healthcare provider to proceed with relocation of the dislocated radial head. This is accomplished by following these steps:
1. If possible, have the child sit comfortably in the mother's or the father's lap. The child will feel more secure and be more cooperative if anxiety is decreased.
2. The healthcare provider stabilizes the elbow and applies pressure over the radial head while supinating the forearm. A pop may be heard, or a sensation of the radial head popping back into place should be anticipated. Pronation and supination of the forearm are more easily performed (see Figure 4a).
3. If reduction is not achieved, the forearm should be supinated; flexion of the elbow should occur, at which time the radial head will be reduced and a pop may be heard or sensed when reduction occurs (see Figure 4b).
Following the reduction of the nursemaid's elbow, the child will often demonstrate less pain almost immediately. Most children will assume normal activities within minutes of the reduction. The child should be observed for several minutes to ensure that the child is willing to use the extremity again and that the pain has subsided.
If the child continues to demonstrate behavior related to pain, reevaluation of the extremity for deformity and motion should occur to rule out the failure of reduction. Generally, radiographs are obtained when attempts at relocation fail when the nursemaid's elbow is the suspected diagnosis.
Caitlin was a 28-month-old girl who had been playing happily with her older siblings in the backyard. In a game of hide-and-seek, the older brother quickly grabbed the toddler and dragged her behind the shed to hide from the other siblings. History revealed that the child immediately began to cry and began holding her left arm tightly to her body. Several hours went by before the parents returned home from work and found the little girl holding her arm and crying. The brother reported that she had not fallen or injured herself. She was taken to the urgent care center in town where she was evaluated, and radiographs were then obtained to rule out a fracture of the left arm. Reduction of the radial head subluxation was accomplished with immediate relief of crying. The exhausted toddler was discharged from the urgent care center, sleeping in her father's arms.
The family needs to be advised that once a radial head subluxation occurs, it is possible that the subluxation will recur. This is difficult news especially for the guardian who was with the child at the time of injury. Guardians need to be able to verbalize their feelings about this injury. Compliance by all caregivers with preventative measures must occur.
Nursemaid's elbow is a common problem in children between the ages of 1 and 5. Brown (2009) reports that more than 200,000 children were evaluated in emergency departments in 2005-2006 for this injury. This does not account for the unknown number of children who sustain this injury and are treated in urgent care centers or pediatricians' offices. Theoretically, thousands of other children also may have sustained this type of injury during that same time frame, as the treatment for this injury can often be achieved outside of the hospital setting.
A recurring comment from parents following the occurrence of this injury is that they were unaware that playful activities such as swinging the child around by the hands, pulling on an arm when trying to control a child from running into the street, or falling down can cause this type of injury. Pediatric and orthopaedic nurses can be instrumental in educating parents, caregivers, and teachers about how this injury occurs. Although all radial head subluxations cannot be prevented, a thorough discussion with these groups may help decrease the overall incidence. Injury incidents such as catching a falling child, preventing a child from running into traffic, or having a child unexpectedly change direction may result in a nursemaid's elbow. However, playful activities such as pulling on a young child's arm or swinging a young child around by the hands should never occur. The child should always be lifted under the arms to avoid nursemaid's elbow. The less obvious activity of pulling the arm through a tight coat sleeve has also been implicated in nursemaid's elbow; therefore, taking care when dressing the child is important so that excessive pull on the arm does not occur.
As in any injury in this age-group, injuries in young children should always be assessed for possible signs of child abuse. The healthcare provider who is assessing the injury needs to consider child abuse in nursemaid's elbow. Appropriate questions to determine the mechanism of injury and whether inconsistencies exist in the description of the occurrence should be evaluated. Nursemaid's elbow does present a difficult scenario as recurrence can be seen and is not necessarily related to a child abuse situation.
Nursemaid's elbow is a common injury in children between the ages of 1 and 5 years. Parents, teachers, and other healthcare providers who come in contact with children in this age-group should be educated about the mechanism of this injury and common precipitating events during routine pediatric office visits and continuing education programs.
Brown, D. (2009). Emergency department visits for nursemaid's elbow in the United States, 2005-06. Orthopaedic Nursing, 28, 2. [Context Link]
Hart, E., Grottkau, B., Rebello, G., & Albright, M. (2006). Broken bones: Common pediatric upper extremity fractures-part II. Orthopaedic Nursing, 25(5), 311- 323. [Context Link]
Kunkler, C. (2000). Did you check your nursemaid's elbow? Orthopaedic Nursing, 19(4), 49-52. [Context Link]
Schultzman, S. A., & Teach, S. (1995). Upper-extremity impairment in young children. Annals of Emergency Medicine, 26, 474-479. [Context Link]
Vitale, M., & Mooney, D. (2005). In D. Wesson, D. Bensard, A. Cooper, T. Scherer, S. Stylianos, & D. Tuggle (Eds.), Pediatric trauma: Pathophysiology, diagnosis, and treatment (p. 389). New York: Taylor & Francis. [Context Link]
Waanders, N. A., Hellerstein, E., & Ballock, R. T. (2000). Nursemaid's elbow: Pulling out the diagnosis. Contemporary Pediatrics. Retrieved February 18, 2009, from http://contemporarypediatrics.mediwire.com/main/Default.aspx?P=Content&ArticleID[Context Link]
Back to Top