Nursemaid Elbow: Symptoms, Types, Causes and Treatment

Nursemaid elbow, also known as pulled elbow or radial head subluxation, is a common childhood injury that often occurs during play or routine activities. Although it can be distressing for both children and caregivers, nursemaid elbow is generally straightforward to diagnose and treat when recognized promptly. This article provides a comprehensive overview of its symptoms, types, causes, and treatment approaches, drawing on the latest research and clinical studies.

Symptoms of Nursemaid Elbow

Nursemaid elbow presents with clear and distinct symptoms that can cause worry for parents and caregivers. Being able to recognize these signs quickly is essential for prompt intervention and relief.

Main Symptom	Description	Age Range	Source(s)
Pain	Sudden, acute pain in affected arm	1–5 years	1, 2, 7
Loss of Motion	Refusal to use or move the arm	Primarily toddlers	2, 7, 10
Tenderness	Localized tenderness at elbow	All ages	2, 10
No Swelling	Absence of visible swelling	Most cases	2, 7, 10

Table 1: Key Symptoms

Recognizing the Symptoms

The hallmark symptom of nursemaid elbow is a sudden reluctance or refusal by the child to use the affected arm. This often occurs after a distinct event, such as being pulled by the hand or wrist. The child may cry out in pain, hold the arm limp at their side, and avoid any movement, especially at the elbow. Importantly, the child typically refuses to bend or supinate (turn palm up) the affected forearm, often keeping it slightly flexed and pronated (palm down) 1, 2, 7, 10.

Pain and Loss of Function

• Acute Pain: The pain is usually sharp and immediate, occurring right after the injury. Children may cry or become irritable, especially if movement is attempted.
• Impaired Use: Affected children often refuse to use their arm for normal activities, such as feeding themselves, playing, or even reaching out 2, 7.
• Absence of Swelling or Deformity: Unlike fractures or severe trauma, nursemaid elbow rarely presents with swelling, bruising, or visible deformity. The absence of these signs can help differentiate it from more serious injuries 2, 10.

Physical Exam Findings

• Tenderness: There is often localized tenderness over the lateral aspect of the elbow, but the joint appears otherwise normal 2, 10.
• No Neurological Deficit: Sensation and circulation in the hand and fingers are typically unaffected.

Recognizing these key symptoms can prompt caregivers and clinicians to act swiftly, minimizing distress and preventing unnecessary interventions.

Types of Nursemaid Elbow

Nursemaid elbow is not a one-size-fits-all condition. Recent advances in imaging and clinical research have identified different types based on the underlying ligament involvement and response to treatment.

Type	Description	Key Feature	Source(s)
Type I	Annular ligament interposed, intact	Quick recovery post-reduction	3
Type II	Annular ligament torn	May need splinting, slower recovery	3
Recurrent	Multiple episodes over time	Recurrence, may need special management	10, 12

Table 2: Nursemaid Elbow Types

Type I: Interposed Annular Ligament

The most common type involves the annular ligament slipping over the head of the radius and becoming interposed in the joint without tearing. Children with this type respond dramatically to reduction maneuvers, often resuming normal arm use almost immediately 3.

Type II: Torn Annular Ligament

In a minority of cases, the annular ligament is partially or completely torn, which can lead to delayed recovery or persistent symptoms even after reduction. These cases may benefit from additional interventions, such as splinting, and careful follow-up to ensure healing 3.

Recurrent Nursemaid Elbow

Some children experience repeated episodes of nursemaid elbow, defined as three or more occurrences. These children may have increased ligament laxity or other anatomical predispositions. Management strategies for recurrent cases might differ and can include education for caregivers and, in rare circumstances, orthopedic referral 10, 12.

Imaging-Based Classification

High-resolution ultrasound has enhanced our understanding of the underlying pathology, helping clinicians distinguish between ligament interposition and tears. This imaging can also guide post-reduction management and identify children at risk for recurrence 3.

Causes of Nursemaid Elbow

Understanding the causes of nursemaid elbow is crucial for both prevention and effective management. While the classic mechanism is well known, research highlights a broader range of causes than previously thought.

Cause Type	Mechanism	Typical Age	Source(s)
Axial Traction	Pull on extended, pronated arm	1–5 years	2, 7, 10
Nonaxial Trauma	Fall, direct blow, rolling over	Mainly toddlers	9, 10
Repetitive	Recurrent minor trauma	Any, often toddlers	10, 12

Table 3: Common Causes

Classic Axial Traction

The most frequent cause is a sudden pull on the child’s outstretched, pronated arm. This can happen when:

• Lifting a child by the hands or wrists
• Swinging a child by the arms during play
• Pulling a child away from danger 2, 7, 10

This traction causes the annular ligament to slip over the radial head, leading to subluxation.

Nonaxial Trauma

Recent studies show nursemaid elbow can also result from mechanisms other than axial traction. These include:

• Falls: Landing awkwardly on an outstretched arm
• Direct Blows: A hit to the elbow region
• Rolling Over: Especially in infants while changing positions 9, 10

In these cases, the injury may not be immediately linked to a pulling event, and the history may be less clear.

Repetitive Minor Trauma

Children with increased ligament laxity or previous episodes may develop nursemaid elbow more easily, even with minimal trauma. Recurrent cases are particularly important to recognize, as they may occur with seemingly minor incidents 10, 12.

Age-Related Susceptibility

Nursemaid elbow is most common in children under the age of five, peaking around two to three years old. This is due to the unique anatomy of the pediatric elbow—the annular ligament is relatively loose and the radial head is not yet fully developed, making subluxation more likely 2, 7, 10.

Treatment of Nursemaid Elbow

Treatment for nursemaid elbow is usually straightforward, highly effective, and provides almost immediate relief. However, understanding the nuances of different reduction techniques is essential for optimal care.

Method	Description	Success Rate	Source(s)
Hyperpronation	Forced pronation of forearm	66–87% (1st attempt)	4, 5, 10, 11
Supination-Flexion	Supination + elbow flexion	53–72% (1st attempt)	4, 5, 11
Splinting	Immobilization post-reduction	For torn ligaments or recurrence	3, 2
Home/Remote	Guidance via phone for reduction	Selected cases	12

Table 4: Treatment Approaches

Standard Reduction Techniques

There are two principal manual maneuvers used to reduce nursemaid elbow:

• Hyperpronation: The forearm is forcefully turned so the palm faces downward while the elbow is supported. Multiple studies and meta-analyses find this method more effective and less painful for children, with higher first-attempt success rates compared to the supination-flexion technique 4, 5, 10, 11. Hyperpronation is now widely recommended as the first-line maneuver.
• Supination-Flexion: This traditional method involves supinating (turning the palm up) and simultaneously flexing the elbow. While commonly taught, it has lower success rates and can be more painful, especially if used after a failed hyperpronation attempt 4, 5, 11.

A palpable or audible "click" is often felt during successful reduction, and children typically regain use of their arm within minutes 10.

Splinting and Additional Interventions

In cases where the annular ligament is torn (Type II) or symptoms persist after reduction, splinting the elbow for several days can support healing. This is especially relevant for children with recurrent episodes or delayed recovery 3, 2.

Imaging and Exclusions

If the mechanism of injury is unclear, or if there are signs of swelling, deformity, or persistent pain after reduction, an X-ray is warranted to rule out fractures. Manipulation should be avoided if a fracture is suspected 1, 2, 8.

Home and Remote Management

Emerging evidence supports the possibility of guided reduction at home or via telephone instructions for trained caregivers in specific situations, though this should only be attempted with proper guidance and in the absence of complicating factors 12.

Prevention and Education

After successful treatment, educating caregivers about the mechanism and prevention of nursemaid elbow is crucial. Advising against pulling or swinging children by the arms can help prevent recurrence, especially in children with a history of repeated episodes 10, 12.

Conclusion

Nursemaid elbow is a frequent and distressing yet easily treatable injury in young children. Prompt recognition, correct diagnosis, and appropriate management can ensure a rapid return to normal activities and prevent complications.

Key Takeaways:

• Recognize Symptoms: Sudden refusal to use the arm, pain, and lack of swelling should raise suspicion for nursemaid elbow in young children.
• Understand Types: Most cases involve an intact but interposed annular ligament, though some may have a torn ligament or recurrent episodes.
• Identify Causes: Classic traction injuries are most common, but falls, direct blows, and rolling over can also cause nursemaid elbow.
• Prioritize Treatment: Hyperpronation is the most effective and least painful reduction maneuver. Supination-flexion may be used secondarily.
• Educate Caregivers: Prevention and recurrence reduction rely on proper handling and awareness of risk factors.

With awareness and proper technique, nursemaid elbow can be resolved quickly, minimizing distress for both children and families.