Nursemaid’s Elbow

Dr. Greene:

What an ordeal, indeed. When a joint is out-of-place for that long, it’s not unusual for a child to be sore the following day. It’s a good sign your son is (thankfully!) again using his arm today. Typically the soreness from nursemaid’s elbow should decrease steadily from here.

• For most kids with nursemaid’s elbow, once the elbow has been put back in place, that’s the end of the story. But for more than 1 in 4 kids (27% to 39%, depending on the study) the whole thing happens again. Given your son’s story, the risk could be on the higher end.
• If nursemaid’s elbow recurs, it’s usually from force in the same direction, with the arm in the same position as the first time. Most commonly, this happens when the arm is pulled when the elbow is straight and the wrist is pronated (the elbow-wrist alignment he would be in with his arm stretched in front of him, palm down). This is true for more than half of kids.
• The headline to share with caregivers for preventing recurrence is, “avoid sudden pulling on his arms, especially when the arm is straight.”
• Each joint is unique – for some it’s a different motion, such as a twisting motion, that triggers it.

What if This Happens Again?

Whenever a child shows up in an ER with nursemaid’s elbow, most pediatricians and ER docs use something called the supination/flexion method to get the elbow back in place. It’s quick, easy and works – most of the time. When it doesn’t, they may be stymied and wait for an orthopedist. The hyperpronation technique almost always works when the first method doesn’t and is also very easy to do (and hurts less!), but many haven’t heard of it.

If your son is that 1 in 4, and despite your best efforts you find yourselves in the ER again, you can give them this reference: “A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 102(1):e10″. In this series of 90 kids at Baylor ER, all 6 who failed with the first technique were successfully treated with hyperpronation, 5 on the first attempt and 1 on the second.

Thankfully, the annular ligament of your son’s elbow will eventually grow thick and strong enough to prevent nursemaid’s elbow from ever happening again. It typically occurs in kids 1 to 4 years old, with a peak at 2 to 3. For kids who’ve had it once, it hardly ever recurs after age 4 or 5 (though I have seen it once in a 7-year-old).