Nursemaid’s elbow, also known as a pulled elbow or radial head subluxation, is an injury my family is all too familiar with. Before Jacen got his diagnosis of Ehler’s Danlos Syndrome, he had dislocated his elbow over 80 times between age 2 and 4. Yes, over 80 times.
What is a nursemaid’s elbow?
Nursemaid’s elbow means the elbow has slipped out of its normal place at the joint, also called dislocation or subluxation. This happens in toddlers because the ligaments that hold the elbow in place are still very flexible and weak. Ligaments are much stronger by the time a child turns 5, which is usually when a child will stop dislocating their elbow.
What causes a nursemaid’s elbow?
For most patients, a nursemaid’s elbow is considered a mild and common injury. It typically occurs in toddlers before the bones in the elbow are completely formed. The most common cause of a pulled elbow is playing the “swinging game” where adults hold a child’s hand and swing the child in circles. Basically any twist or pull can cause the injury, so even children who avoid swinging by the arms may pull their elbow out while being caught during a fall, throwing themselves to the ground during a tantrum, playing on the monkey bars or while being encouraged to walk quickly by holding their hand and lightly pulling them along. In Jacen’s case, his elbow was so loose that it would come out when he tried to pull a drawer open, pull himself out of a bucket-style car seat, climbing a ladder to use a slide, or trying to pull his arm through a jacket sleeve.
How is pulled elbow treated?
Most providers can diagnose a pulled elbow simply from observing a child. A child with a true dislocation will not use or move their arm. It’s possible that the child does not feel any pain at all, but only has mobility symptoms. The provider will then palpate the elbow (feel the elbow with their hands) to confirm the joint is out of place.
An X-ray is typically not necessary to diagnose a pulled elbow, but is sometimes ordered to rule out minor fractures in addition to the pull. For frequent offenders, like Jacen, doctors may avoid an x-ray at each dislocation to avoid excessive exposure to radiation. Typically imaging is only used AFTER the provider has attempted to reduce the subluxation, but the child still shows signs of injury.
The provider will reduce the injury by cradling the elbow in one hand, then using their other hand to move the child’s forearm up into a flex, then back down to an extended straight arm. The best analogy I can give is when a drawer comes “off the track” in your dresser, and you have to open and close the drawer multiple times, slightly twisting and readjusting with each new open motion.
The actual reduction may be temporarily painful as the joint scrapes back into place, sometimes touching painful nerves or ligaments on its way back in. When the elbow is back in place, the relief is basically immediate. The pain eases, and the child will immediately be able to use it again.
Your child will be observed to make sure using their arm does not continue to cause problems or pain. Most cases do not require any ice, medication, wraps, brace or cast.
What does a pulled elbow feel like for my child?
Some children do not feel pain while the joint is “out,” but only show signs of injury by not using the arm.
The procedure of reduction is temporarily painful and distressing, but it only lasts a short moment and is over when the radial bone pops back into place. As stated above, relief is almost instant.
How do I prevent a pulled elbow?
For most children, avoiding swinging a child by their arms is enough to prevent pulling an elbow. In other kids, it might not be possible to prevent. Sometimes it is just genetics; the shape of the elbow, and the rate of growth/strength of the ligaments in the arm. For kids like Jacen who have chronic dislocations, braces or casts may be used as a preventative measure. By keeping the arm immobilized, the ligaments have a chance to grow bigger and stronger without constantly being beat down by the bones in the joint rubbing against them.
A few of Jacen’s doctors showed me how to reduce his elbow myself, but it just wasn’t something I was ever comfortable with. Sometimes the joint went back on its own. The loose ligaments let the joint move both ways, both out of place and back into place. If it did not go back on its own we sought medical treatment. It is not typically necessary to head into the Emergency Room. Pediatricians, orthopedic doctors and most urgent care providers are able to help in the office. We ended up in the ER when the dislocation happened during hours the pediatrician was closed, and the times he did not get relief and required a follow up x-ray.
After two years of almost constant dislocations, Tufts Medical Center suggested we cast his elbow for 4 weeks to let the ligament rest and grow. In November of 2013 Jacen picked out an awesome red cast, which he got to show off at our wedding. (Note the adorable picture of Jacen in a suit, cast, and captain hat!) He had no pain or issues while wearing the cast, but we were hesitant to accept this as a miracle cure. We didn’t want to get our hopes up.
Luckily the immobilizer worked. After having the cast removed he never had a dislocation again. I truly believe this was just a lot of luck on our part. He happened to have a growth spurt while wearing the cast, and I truly believe they happened to create the perfect conditions for healing.
I bet it isn’t surprising to hear, but I was over-the-moon thrilled to put this chapter behind us. I hadn’t even thought about his elbows for years! Well, a few weeks ago I got a call from my sister- my niece wasn’t using her arm. She had pulled her elbow while being taken out of her high chair. Luckily for my beautiful Nora, her elbow went back into place on its own before her parents could even get her to the doctor. It just goes to show you that this condition is not specific to Ehlers-Danlos patients, but to any child.
Swinging your kid is a timeless activity, especially popular with older generations. I beg you to stop, and make sure your friends and family know to stop. Instead, hold children under their armpits or hug them to your body. If you suspect your child your child has pulled their elbow out of place, monitor their activity for 10-15 minutes paying attention to how they use their arm. If the arm is hanging, limp by their side, it’s time to seek medical intervention. If they begin using their arm again the joint has likely fixed itself on its own. When in doubt, ask the child to put the good arm behind their back and catch a light ball or small toy. If the arm in question instinctively moves to catch or shield the toy their elbow is likely fine. If the toy is not deflected, or they take the arm from behind their back, it’s time to head into the doctor.
Stay educated. Stay healthy. Stay safe.
Kate and the Kids