Nursemaid's elbow

Nursemaid's elbow is a common type of elbow injury in young children. It happens when a ring-shaped ligament near the elbow slips out of its usual position. A ligament is a strong band of tissue that helps hold a joint together.

The injury is not a complete elbow dislocation. The bones have shifted only slightly, but the trapped ligament can make movement painful. A child will often stop using the affected arm and hold it close to their body.

Nursemaid's elbow usually affects children younger than 5. Their elbow structures are still developing, and the ligament can slip more easily than it does in an older child. The injury becomes uncommon as the ligament strengthens and fits more securely around the bone.

A trained health professional can usually correct the problem with a quick movement called a reduction. This guides the ligament and joint back into position. Most children begin using the arm normally soon afterward and have no lasting damage.

Symptoms often begin immediately after the arm has been pulled, lifted, or twisted. However, nobody may have seen exactly what happened.

A child with nursemaid's elbow may:

• Stop using one arm or refuse to reach for objects
• Hold the arm close to their side, with the elbow slightly bent
• Keep the palm facing down or inward
• Cry when the elbow, wrist, or forearm is moved

The child may describe pain in the elbow, wrist, or forearm. Very young children may not be able to say where it hurts.

There is usually little or no swelling, bruising, or visible change in the arm's shape. Marked swelling, bruising, or deformity is less typical and may suggest a fracture or another injury.

Nursemaid's elbow most often happens when a child's straight arm is pulled suddenly. The pulling force travels along the forearm and allows the ligament at the elbow to slip out of position.

This can happen when someone:

• Lifts or swings a child by the hands or wrists
• Pulls a child up from the floor by one arm
• Tugs a child's hand as the child pulls away or falls
• Catches a child by the hand to prevent a fall

It can also happen during play, while getting dressed, or when a child rolls over an arm. In some cases, there is no clear pulling event.

Young age is the main risk factor. Children who have had nursemaid's elbow before may have another episode because the ligament can remain relatively loose until they grow. A repeat episode does not usually mean that the elbow has been permanently damaged.

Nursemaid's elbow is not inherited. An accidental episode also does not, by itself, mean that someone handled the child carelessly; ordinary movements can sometimes cause it in a susceptible young child.

Nursemaid's elbow is usually diagnosed from the story of what happened and an examination of the arm. The health professional will look at how the child holds the arm and check for swelling, bruising, tenderness, deformity, and problems with blood flow or feeling.

An X-ray is not usually needed when the symptoms and examination are typical. The slipped ligament generally cannot be seen on a standard X-ray.

An X-ray may be needed if:

• The injury involved a fall, direct blow, or other significant force
• There is swelling, bruising, deformity, or tenderness over a bone
• The history or examination does not fit nursemaid's elbow
• The child does not begin using the arm after reduction
• A fracture or other condition needs to be ruled out

Beginning to move the arm again after reduction supports the diagnosis. If movement does not return as expected, the arm should be reassessed rather than assuming the reduction worked.

Treatment is a brief reduction performed by a trained health professional. They move the forearm and elbow in a controlled way to release the ligament and restore the joint's normal position.

There are two commonly used reduction techniques. Both involve rotating the forearm, sometimes while bending the elbow. The procedure may cause a few seconds of discomfort. Sedation or an anaesthetic is not usually needed.

Some children start using the arm within a few minutes. Others may take 15 to 30 minutes, especially if they are frightened or the injury has been present for several hours. Offering a toy, snack, or familiar object can help show whether normal movement has returned.

If the first reduction attempt does not work, the health professional may repeat it or use the other technique. Continued pain or refusal to use the arm may lead to an X-ray, temporary support such as a sling, or further assessment.

A sling, cast, or surgery is not normally needed after a successful reduction. The child can generally return to comfortable, ordinary activity. Pain medicine may sometimes be suggested, but treatment should follow the advice given for that child.

Do not try to reduce the elbow at home. A fracture can look similar, and pulling or twisting an injured arm without an examination may cause unnecessary pain or delay the correct treatment.

Complications from nursemaid's elbow are uncommon. After a successful reduction, the ligament and joint generally recover without affecting arm growth, strength, or movement.

The main ongoing issue is recurrence. The elbow may slip again during another pulling event, particularly during the next few years. Children usually outgrow this tendency as the elbow matures.

Persistent pain or limited movement is not typical after recovery. It may mean that the ligament has not returned to position, or that another injury such as a fracture is present.

Problems are more likely to arise from a missed alternative diagnosis than from nursemaid's elbow itself. This is why swelling, deformity, significant bruising, or continuing symptoms need further assessment.

Not every episode can be prevented. Nursemaid's elbow can happen during an ordinary fall, roll, or quick movement.

To reduce the chance of a pulling injury:

• Lift a young child from under the arms rather than by the hands
• Avoid swinging a child by the hands, wrists, or forearms
• Do not pull a child up steps or off the floor by one arm
• If a child drops to the ground, release their hand rather than tugging upward

Family members, childcare workers, and other caregivers can use the same precautions. These steps are especially helpful after a child has already had an episode.

For most children, nursemaid's elbow is a short-lived injury rather than an ongoing condition. Once the ligament is back in position, normal arm use usually returns quickly. An uncomplicated episode does not generally require activity restrictions or routine follow-up.

Some children have repeat episodes over months or years. This can be upsetting, but it does not usually mean that the joint is becoming weaker. The tendency fades as the ligament thickens and the elbow bones mature, usually by early school age.

If another episode occurs, the child should be assessed again. A previous diagnosis does not prove that every later arm injury is nursemaid's elbow.

Symptoms in an older child, or symptoms that continue after attempted reduction, need a careful review for fractures and other causes. Most children with a straightforward episode go on to use the arm normally without long-term pain or disability.

Seek prompt, same-day medical assessment if a child suddenly stops using an arm after it was pulled, lifted, twisted, or caught. Assessment is also appropriate when the cause is unclear, because fractures and other injuries can cause similar behaviour.

After a successful reduction, routine follow-up is usually unnecessary unless the health professional recommends it. Arrange reassessment if the child still avoids using the arm later that day, has pain the following day, or develops new swelling or bruising.

Seek urgent medical care if the child has:

• Marked swelling, bruising, or a visibly bent or misshapen arm
• Severe or worsening pain
• A hot, red, swollen joint, especially with fever
• An open wound near the injury
• Symptoms after a major fall, collision, or direct blow
• Continued refusal to move the arm after reduction

Get emergency help if the hand becomes pale, blue, cold, numb, or unusually weak, or if the child cannot move their fingers. These signs may mean that blood flow or nerves are affected. Heavy bleeding or a major traumatic injury also needs emergency care.

Is nursemaid's elbow a real dislocation?

It is a partial shift rather than a complete elbow dislocation. A ligament slips over part of a forearm bone near the elbow and becomes caught. The arm usually looks normal even though movement hurts.

Can nursemaid's elbow fix itself?

It occasionally slips back into place before the child is examined. Even so, persistent refusal to use the arm needs assessment. Do not repeatedly test, pull, or twist the arm to see whether it has improved.

How quickly will my child use the arm after treatment?

Many children begin reaching and playing within several minutes. It can take around half an hour, and sometimes longer if the injury occurred many hours earlier. Continued refusal to use the arm needs reassessment.

Can I put nursemaid's elbow back in place at home?

No. A trained health professional should first check for signs of a fracture or another injury. Home reduction attempts may hurt the child and could delay treatment of a different problem.

Does nursemaid's elbow show up on an X-ray?

The slipped ligament usually does not show on a standard X-ray. X-rays are mainly used when the examination is not typical or when a fracture is possible.

Will it keep happening?

It may happen again while the elbow is still developing. Avoiding lifting or swinging the child by the hands can reduce the risk. Most children outgrow the tendency by early school age.