Pulled elbow, also referred to as the Nursemaid’s elbow is a frequently encountered condition characterized by the partial dislocation of the radius bone of the elbow joint. This common injury occurs when the radial head slides under the annular ligament, which causes pain to the individual, particularly in a supine position of the forearm. It is common in young children as their ligaments and joints are still growing and do not require a lot of force to get pulled out of place. (1) (2)
Causes Of Pulled Elbow
Pulled elbow is most commonly caused by a sudden pull of the arm, particularly when it is extended. A common instance where this may be seen is when the child is lifted or is swinging by the arms. The elbow injuries caused by such movement can cause the slippage of the annular ligament, which further leads to the ligament being stuck between the humerus and radius. The annular ligament is normally present around the radial head, holding it against the Ulna bone of the arm. When the annular ligament slips over the head of the radius bone in an extended elbow joint, it leads to a pulled elbow. It can be caused by a simple act such as pulling arm of the children in order to prevent them from tripping, which leads to radial head subluxation. (3)
Symptoms Of Pulled Elbow
Children which a pulled arm often have a history of their arm being pulled from its normal position by the wrist by a caregiver, leading to their symptoms. The symptoms usually start when the child falls onto their outstretched arm. When presenting to the doctor, the children are often holing their injured arm in a protective way, with their unaffected arm. The injured arm is either in a complete extension of pronation, or the child refuses to move their arm, as it causes pain. Other than pain, the children may also report tenderness over the radial head, which keeps them from pronation, supination, and flexion of their arms. There is often no associated redness, ecchymosis, or edema.
Diagnosis Of Pulled Elbow
The paediatric or healthcare physician first starts by carefully inspecting the injured arm and the clavicle of the same side. The arm is then examined for any tenderness on palpation over the joints. The pulled elbow or radial head subluxation diagnosis is most commonly made after considering the clinical signs and symptoms. Imaging techniques like x-rays are often not required for the diagnosis of a pulled arm, but it may be recommended when the emergency medicine doctor suspects a case of trauma, elbow dislocation, or fracture of the elbow. It may also be recommended when the doctor suspects the pulled elbow to be caused by an unusual mechanism or they suspect a case of abuse. (4) (5) (6) (7)
Treatment For Pulled Elbow
The most commonly recommended treatment for pulled elbow is the closed reduction method, which may be conducted within seconds. While this is a very short procedure, the reduction of the annular ligament back to its normal position can be quite painful for the patient. This is why the emergency paediatric doctor should give a disclaimer to the parents of the caregiver that it might upset the child. However, once the elbow reduction has been conducted properly, the pain usually resolves immediately. During the examination before the procedure, the child’s carers may also be asked to hold the arm of the child to make them more comfortable. If the child is in a lot of pain, they may be recommended pain killers like paracetamol and ibuprofen. While they will provide pain relief, the dosages and frequency of intake should be according to medical advice and NHS recommendations. (8) (9)
More specifically, the two methods of reduction of the subluxated radial head in the emergency department include Hyper pronation and the Supination and flexion method. Experts believe the hyper pronation technique is more successful for first-timers than the supination and flexion method. It is also less painful as compared to the supination and flexion method. However, if the hyper pronation technique remains unsuccessful, the paediatric healthcare worker may use the supination and flexion method as the second choice.
In order to perform the hyper pronation technique, the doctor supports the child’s elbow while applying a moderate level of pressure onto the radial head. With the opposite hand, the doctor then makes the forearm hyper pronated by applying pressure to the wrist. If the manoeuvre is successful, a click is heard.
In order to perform the supination and flexion method, the health professionals start by applying light pressure to the radial head with their thumb, meanwhile providing support to the child’s elbow with the same hand. The doctor then uses their other hand to hold the patient’s distal forearm. The doctor ensures that the forearm is fully supinated and flexed using slight traction. If a click is heard, the manoeuvre is considered to be successful. (10)
Frequently Asked Questions
How long does it take for a pulled elbow to heal?
The pulled elbow may take up to four weeks to heal. During this time, the doctor may recommend sessions with a physical therapist to help the affected child with the required stretching and strengthening exercises.
Can you see pulled elbow on the x-ray?
A nursemaid’s elbow or a pulled elbow is often not evident in an ordinary x-ray. Hence, a case like this may appear completely normal on an x-ray if it is not associated with any trauma.
Can be pulled elbow correct itself?
The pulled elbow may sometimes correct itself; however, this does not always happen. Hence it is recommended to consult a health professional whenever the parents of the caregiver suspect a case of a pulled elbow. However, the pulled elbow does not lead to any long-term problems and does not stretch the associated ligament.
What does a strained Elbow feel like?
The common symptoms associated with strained elbow include swelling, tenderness, and pain felt by the patient during movement. This may also be felt during rest around the elbow area.
Can you pull your elbow out of the socket?
An elbow may become dislocated when one of the three bones associated with the elbow joint gets pulled out of its normal location. This may present with immediate pain and the patient being unable to move their arm.
- Mohd Miswan, M. F., Othman, M. S., Muhamad Effendi, F., Ibrahim, M. I., & Rozali, K. N. (2017). Pulled/Nursemaid’s elbow. Malaysian family physician : the official journal of the Academy of Family Physicians of Malaysia, 12(1), 26–28.
- Wong, K., Troncoso, A. B., Calello, D. P., Salo, D., & Fiesseler, F. (2016). Radial Head Subluxation: Factors Associated with Its Recurrence and Radiographic Evaluation in a Tertiary Pediatric Emergency Department. The Journal of emergency medicine, 51(6), 621–627. https://doi.org/10.1016/j.jemermed.2016.07.081
- Nardi NM, Schaefer TJ. Nursemaid Elbow. [Updated 2021 Aug 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430777/
- Chen, H., Shao, Y., & Li, S. (2019). Replacement or repair of terrible triad of the elbow: A systematic review and meta-analysis. Medicine, 98(6), e13054. https://doi.org/10.1097/MD.0000000000013054
- Wang, Q., Du, M. M., Pei, X. J., Luo, J. Z., Li, Y. Z., Liu, Y. C., Wang, X., Cao, J. C., & Han, J. H. (2019). External Fixator-assisted Ulnar Osteotomy: A Novel Technique to Treat Missed Monteggia Fracture in Children. Orthopaedic surgery, 11(1), 102–108. https://doi.org/10.1111/os.12426
- Cope, B., & Tracy, M. (2018). Not just another nursemaid’s: an enigmatic paediatric humeral fracture. BMJ case reports, 2018, bcr2017222925. https://doi.org/10.1136/bcr-2017-222925
- Pawelec, B., Waśko, M. K., & Pomianowski, S. (2018). Neglected Iatrogenic Elbow Joint Dislocation. Didactic Case Report. Ortopedia, traumatologia, rehabilitacja, 20(1), 57–63. https://doi.org/10.5604/01.3001.0011.5877
- Galbiatti, J. A., Cardoso, F. L., Ferro, J., Godoy, R., Belluci, S., & Palacio, E. P. (2018). Terrible triad of the elbow: evaluation of surgical treatment. Revista brasileira de ortopedia, 53(4), 460–466. https://doi.org/10.1016/j.rboe.2018.05.012
- Krul, M., van der Wouden, J. C., Kruithof, E. J., van Suijlekom-Smit, L. W., & Koes, B. W. (2017). Manipulative interventions for reducing pulled elbow in young children. The Cochrane database of systematic reviews, 7(7), CD007759. https://doi.org/10.1002/14651858.CD007759.pub4
- Ulici A, Herdea A, Carp M, Nahoi CA, Tevanov I. Nursemaid’s Elbow – Supination-flexion Technique Versus Hyperpronation/forced Pronation: Randomized Clinical Study. Indian J Orthop. 2019 Jan-Feb;53(1):117-121. doi: 10.4103/ortho.IJOrtho_442_17. PMID: 30905991; PMCID: PMC6394198.