Background

Nursemaid elbow, also known as “radial head subluxation” or simply “pulled elbow”, is the most common upper-limb injury in children under the age of 6.^[1] It is typically an easily treatable condition. Correct diagnosis is the primary challenge to the physician.

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Pathophysiology

 The etiology is movement of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn. As children age, the annular ligament strengthens. In children over the age of 5, subluxation of the radial head is prevented by a thicker and stronger attachment between the annular ligament and the periosteum of the radial neck.^[2]    As a result, nursemaid’s elbow occurs less often.

A Nursemaid’s Elbow (NE) is a low-energy trauma often occurring from brisk axial traction of the forearm, often by an adult who holds the child’s hand as the child pulls away. Other causes of injury include falls, wrestling, and abuse.^[3]

The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm. The common belief that nursemaid elbow is due to children having a radial head smaller than the radial neck is incorrect.

Epidemiology

Sex

Published case series report a slight predominance in females.^{[4, 5]}

Published case series report a slight left arm predominance in both males and females.^{[4, 5]}

Age

Nursemaid elbow most commonly occurs in children aged 1-4 years. However, it has been reported in patients as young as 4 months and as old as 31 years.^[6]

A study that examined the epidemiological description of radial head subluxation found that the average age of children presenting with nursemaid's elbow was 28.6 months.^[5]

Prognosis

The prognosis is excellent. Parents can be reassured that no permanent injury results from this condition.

For those who have had one occurrence, the chance of recurrence is approximately 20-25%.^{[4, 7]}  Those 24 months and younger may have the greatest risk of recurrence.^[7]

Patient Education

Most parents appreciate knowing that reoccurrence can occur in 1/5-1/4 of patients.

Clinical Presentation