Nursemaid's Elbow

Introduction

Physical Therapy in Congress Park, Denver Downtown, Central Park, and Highlands Area for Pediatric Issues

Welcome to Atlas Physical Therapy’s guide to nursemaid's elbow.

Nursemaid’s elbow is a common injury in young children. It occurs most often around age two and is rarely seen after age eight. Lifting the child up a step by the hand, giving the hand a sudden jerk, or pulling the child away from a dangerous situation can result in a subluxation or complete dislocation of one of the bones in the elbow. This condition is also known as pulled elbow or radial head dislocation.

This guide will help you understand:

  • what can cause this condition
  • what the symptoms are
  • how your health care professional will diagnose the condition
  • what treatment options are available
  • what Atlas Physical Therapy’s approach to rehabilitation is

Hear from some of our Pediatrics patients
I had been referred to Alex at Atlas by several different people, but it ended up being my daughter's plantar fasciitis that finally got us in there. He did absolutely great with her really does well...
 I had been referred to Alex at Atlas by several different people, but it ended up being my daughter's plantar fasciitis that finally got us in there. He did absolutely great with her really does well with kids. I don't have any acute injuries at this point, but while I was in there with her, I asked about various ongoing issues/problem areas I have, and ended up beginning treatment with him as well. He takes a well rounded and very practical approach that for us has included tissue work (both), dry needling (me), ultrasound (her), adjustments (me), and obviously various exercises and stretches. The rest of the staff there is great as well. Highly recommend. 
Dan O
Denver, CO
My son's pediatrician recommended PT due to a sports injury. Wow! What a welcoming place Atlas Physical Therapy has been! The staff are accommodating, helpful, and friendly right from the start!...
 My son's pediatrician recommended PT due to a sports injury. Wow! What a welcoming place Atlas Physical Therapy has been! The staff are accommodating, helpful, and friendly right from the start! Sophie at the front desk worked around our vigorous schedule! Dr Nikhil gave great recommendations and listened well to my son's needs. Frank's patience allowed them to find the best theraputic exercises without over doing it. Frank even ensured the best form was used so my son would continue to exercise the "correct way." Would highly recommend anybody needing PT to stop by and see what a difference this place makes! 
M U
Denver, CO
Alex is an excellent PT. He knows what he is doing, is a wealth of knowledge, is straight forward, upbeat, and helps you recovery quickly to get back to baseline or to competing. I am driving my...
 Alex is an excellent PT. He knows what he is doing, is a wealth of knowledge, is straight forward, upbeat, and helps you recovery quickly to get back to baseline or to competing. I am driving my daughter all the way down from Steamboat to see him because he is worth it! 
Kara V
Denver, CO
My daughter saw Nikhil to address ankle pain due to hypermobility. He was great at quickly identifying the issue, explaining it, and prescribing easy and effective exercises that helped very quickly....
 My daughter saw Nikhil to address ankle pain due to hypermobility. He was great at quickly identifying the issue, explaining it, and prescribing easy and effective exercises that helped very quickly. Great experience. 
Sarah J
Denver, CO
My daughter and I are pleased with the staff and service.
 My daughter and I are pleased with the staff and service. 
Tammie N
Denver, CO
My nine-year-old daughter sustained a left knee bone bruise following a fall in gym class at school. This injury also caused her muscles to tighten up around her left knee. Torri was scared and...
 My nine-year-old daughter sustained a left knee bone bruise following a fall in gym class at school. This injury also caused her muscles to tighten up around her left knee. Torri was scared and frustrated, unable to participate in her active lifestyle full of bike riding, walking, hiking, skiing, horseback riding, and gymnastics. Torri began physical therapy with Rick in March 2019 with high hopes of healing. Her and Rick worked very hard together. He guided Torri in a calm and confident manner. Torri learned that she was going to heal fully if she continued to put forth great effort at home with the exercises Rick assigned. She did! Torri is so proud of herself. I (her mother) am so proud of her and so happy with the guidance Rick gave her to get to this point. Torri is back at all her typical activities all thanks to Rick’s hard work and Torri’s determination. Michelle and Torri’s Reddick 
Michelle M
Denver, CO
Alex and staff helped my son Brandon and my daughter Rheannan with arm/back issues. They are an amazing team. I highly recommend their services!!
 Alex and staff helped my son Brandon and my daughter Rheannan with arm/back issues. They are an amazing team. I highly recommend their services!! 
Vanessa S
Denver, CO
My daughter worked with Katie Diffily at Atlas and received great care. Katie was supportive, informative and truly helped my daughter strengthen her injured knee. Katie is kind and related well to a...
 My daughter worked with Katie Diffily at Atlas and received great care. Katie was supportive, informative and truly helped my daughter strengthen her injured knee. Katie is kind and related well to a pediatric patient. My daughter also worked with David, an exercise specialist, who had a wonderful rapport with my daughter. He adjusted exercises as necessary, encouraged my daughter through difficult exercises and made the workouts fun. I would highly recommend Atlas Physical Therapy! 
Carrie W
Denver, CO
I was 34 weeks into my second pregnancy when I started to experience severe back and hip pain to a point where I could barely walk. I was very stressed out considering I had my two year old daughter...
 I was 34 weeks into my second pregnancy when I started to experience severe back and hip pain to a point where I could barely walk. I was very stressed out considering I had my two year old daughter to care for/keep up with and 6 more weeks left before my baby was due. I called my doctor and they referred me over to Atlas. It didn't even cross my mind that this was something that could be solved with physical therapy, but sure enough that is exactly what happened. Karl (Bebendorf, owner of the practice and PT extraordinaire) was immediately able to diagnose me and get me started on recovery. He knew exactly how much PT would be effective but also that I could handle being in the later stages of my pregnancy. I went three times the first week, due to the severity of my pain and lack of mobility, and then twice a week for two more weeks. The sessions, combined with the exercises Karl gave me to do at home, made me virtually pain free by the end of the third week. It was wonderful. Karl was so great. Aside from being extremely experienced and professional, he was very sweet and friendly. I felt like I was in good hands, literally. I also worked with Luke a couple times who was also pretty great. In fact, everyone at Atlas I came in contact with was really nice and professional. Furthermore, being my daughter's primary caregiver, there were times I could't find anyone to watch her and had to bring her with. No one batted an eye and made sure to accommodate her as well as me. To her credit, she was very well behaved (thank you iPad) but when she did get interested in what I was doing, Karl would let her be involved. This review is glowing, I realize, but it is truly the experience I had. I can't express enough how stressed I was from the pain I was having before PT. My second little girl was born exactly two weeks ago and she is perfect. I'm so grateful to Atlas for helping me feel strong and healthy enough to bring her into the world. 
Emily B
Denver, CO
The group at Atlas Physical Therapy are awesome! Alex has been working with my daughter for 2 months, and the difference in her flexibility is amazing!
 The group at Atlas Physical Therapy are awesome! Alex has been working with my daughter for 2 months, and the difference in her flexibility is amazing! 
Shannon D
Denver, CO
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Anatomy

What part of the elbow does this problem affect?

The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).

The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the radial head) meets the humerus. The knob on the end of the humerus is called the capitellum. The capitellum fits into the cup-shaped end of the radius, also called the head of the radius, or radial head. This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down. At the same time, it has to slide against the end of the humerus as the elbow bends and straightens. The joint is even more complex because the radius has to slide against the ulna as it rotates the wrist as well.

In the elbow, two of the most important ligaments are the medial collateral ligament and the lateral collateral ligament. The medial collateral is on the inside edge of the elbow, and the lateral collateral is on the outside edge. Together these two ligaments connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus. These ligaments are the main source of stability for the elbow. They can be torn when there is a severe injury or dislocation of the elbow. These ligaments are not generally injured in the condition referred to as nursemaid's elbow.

There is also an important ligament called the annular ligament that wraps around the radial head and holds it tight against the ulna. The word annular means ring-shaped. The annular ligament forms a ring around the radial head as it holds it in place. This ligament can be torn when the entire elbow or just the radial head is dislocated.

Causes

How does this problem develop?

In young children, the annular ligament of the radial head is thin and weak. A sudden pull on the forearm can tear this soft tissue structure. The radial head is pulled down through the tear. The annular ligament slips into the radiohumeral joint and becomes trapped between the two joint surfaces when the arm is let go. This is a radial head subluxation. When the annular ligament is pinched it causes pain.

This is a common injury in children. A sudden jerk on the arm is the main cause. As mentioned, lifting the child up a step by the hand, giving the hand a sudden jerk, or pulling the child by the hand or forearm away from a dangerous situation can result in an elbow injury of this type. Playing with other children where one child swings the other around by the arms can also result in this injury.  The term ‘nursemaid’s elbow’ dates back to when nursemaids or nannies were the common caregivers who would be minding the children and most commonly holding onto their hands.

As a child gets older, a true elbow dislocation is more common and is often the result of a fall or trauma (rather than just a pull on the hand) which leads to fracture and dislocation. This is a much different and much more serious injury than nursemaid’s elbow. The most common site of the fracture associated with dislocation in this age group is a supracondylar fracture. The fracture is located below the humeral shaft (upper arm bone) where the olecranon (the tip of the elbow) fits into the humerus. The bone is thin here in children.

Symptoms

What does nursemaid's elbow feel like?

These injuries commonly occur in children too young to actually tell a parent or health care provider what happened. In young children, crying and refusing to use the arm while holding it against the body are common behaviors associated with nursemaid's elbow. Pediatricians, family physicians, orthopedic surgeons and Physical Therapists usually recognize the pattern quickly because the injury is so common. Once a health care professional has seen a child with this condition, it is relatively easy to spot.

Pain and an inability to straighten the elbow or supinate the forearm (turn the palm up) are typical. There is often tenderness along the lateral aspect of the elbow (side of the elbow away from the body). Bruising around the elbow several days after the injury is common.

In contrast, if the elbow is fully dislocated, it will look out of joint. There may be dimples or indentations of the skin over the dislocation where the bones have shifted position. Swelling on either side of the elbow may be a sign that there is a bone fracture. Pain can be intense until the arm is relocated.

Diagnosis

How do health care professionals diagnose the problem?

Diagnosis begins with a complete history and physical examination. Your Physical Therapist at Atlas Physical Therapy will ask questions about when the pain began, what your child was doing when the pain started, and what movements your child has avoided since the injury occurred. The history alone will often lead your Physical Therapist to the suspicion of nursemaid’s elbow. Next your Physical Therapist will do a physical examination of the elbow.  They may move the elbow passively to assess the range of motion deficits. Movement with this injury can be very painful, especially as the elbow is extended and supinated. This is another sign that nursemaid’s elbow is the likely cause. Lastly, we will also check for any signs of injury to the nerves or blood vessels.

If your Physical Therapist deducts from the history and physical examination that nursemaid’s elbow is the likely cause of your child’s pain, we will refer you on to your doctor or emergency room for reduction of the joint back into place and possible x-rays.

Atlas Physical Therapy provides services for Physical Therapy in Congress Park, Denver Downtown, Central Park, and Highlands Area.

Our Treatment

Reduction of the joint means that the joint is put back into normal alignment. Closed reduction refers to the fact that the subluxation of the annular ligament and radial head are put back in place without surgery. Generally this procedure is done in a clinic or hospital setting.

The technique of reduction is relatively simple. Once your child is calm and trust is established, the elbow is gently taken through a full range of motion from completely extended to fully flexed. While flexed the forearm is maximally supinated. In some cases, a small pop is felt or heard. This can indicate that the radial head and annular ligament have returned to their normal position.  After relocation your child is encouraged to use the arm.  In many cases, within minutes your child will be using the arm normally. If the child needs to feel more secure, a light splint can be used for a day or two.

It is also possible for the nursemaid's elbow to relocate by itself even before you seek medical aid.

X-rays are consistently negative in children with elbow subluxation or dislocation due to the large amount of fibrous cartilage present around the elbow before the bones are fully formed. It is easy to misinterpret the irregular or fragmented growth lines as fractures. Additional views may be needed to help the radiologist make an accurate diagnosis. Before age five (when the bones start to ossify or become bony) a separation of the growth plate at the end of the bone may go undetected. Many doctors, however, will not even order X-rays if they suspect nursemaid's elbow but will simply try to reduce the subluxation with a gentle manipulation.

If your child continues to exhibit pain after manipulation, however, X-rays may be ordered to make sure that no other injuries are present in the elbow such as a fracture. If the X-rays are normal, then your child will be placed in a sling to rest the painful elbow and will be observed for several days. They will then likely be scheduled to return for re-evaluation in 7-10 days. Over time, the vast majority of cases of nursemaid's elbow resolve spontaneously and only in rare circumstances require any additional treatment.

Rehabilitation

What can be expected from treatment at Atlas Physical Therapy?

Nonsurgical Rehabilitation

Often, if the reduction of the joint is uncomplicated, then as mentioned above, most children require no additional treatment and they are simply just encouraged to use the arm normally. If, however, your child continues to suffer from pain or lack of range of motion after the joint has been reduced (and a fracture has been ruled out,) Physical Therapy is recommended. Atlas Physical Therapy provides services for Physical Therapy in Congress Park, Denver Downtown, Central Park, and Highlands Area.

Initially, the treatment we provide will be focused on relieving any pain your child has. In the clinic we may use modalities such as ice, heat, or taping and will educate you on the use of these modalities at home as well. Taping the elbow can assist in modifying the alignment of the joint and in doing so, decrease the pain your child feels when using the elbow or being active. We may also use other electrical modalities to help treat the pain if we feel it is necessary.

The next part of our treatment will focus on normalizing any deficits that may have developed in the range of motion and strength of your child’s elbow joint. Your Physical Therapist at Atlas Physical Therapy may assist in stretching your child’s elbow while in the clinic and, if necessary, will ‘mobilize’ the joint. This hands-on technique encourages stiff joints to move gradually into their normal range of motion. In addition to the hands-on treatment in the clinic we will also prescribe a series of stretching exercises that we will encourage your child to do as part of a home exercise program. Being that the most common age to suffer nursemaid’s elbow is from two to eight, these exercises will be simple activities that you can incorporate into the everyday activities of your child. For example, if your child is very young, your Physical Therapist may show you some simple games that you can play to encourage your child to improve range of motion with daily activity. If they are older, we may teach them a few specific but simple exercises that will again be encouraged throughout regular daily activity.

Similarly to the range of motion deficits, strength deficits will also be addressed.  Again, your Physical Therapist at Atlas Physical Therapy will show you how to incorporate strengthening exercises into your child’s normal activities such as playing or eating.  Even regular playing with toys, for example, can be used to strengthen your child’s elbow and upper limb.

The final part of our Atlas Physical Therapy treatment will be ensuring that your child’s coordination of the limb has returned to normal after the dislocation. Even a short period of abnormal joint use can cause the coordination and proprioception (the ability to know where your body is without looking at it) to decline in function. Exercises, such as weight bearing through the hand, ball tossing, and rotating the forearm will be encouraged throughout playing and everyday activities once your Physical Therapist determines these are safe activities to undertake. Activities that cause further traction on the elbow, such as pulling a door open or lifting a bag, will be discouraged until full ligamentous healing has occurred, which can take up to 6 weeks depending on the severity of injury.

Education is a fundamental part of our treatment at Atlas Physical Therapy therefore It is worthy to mention that parents of small children are cautioned to avoid pulling or lifting by the hand to prevent injuries or re-injuries of this type. Young children should always be picked up under the arms, especially if they have previously had a nursemaid’s elbow injury. Children should never be forcibly pulled, lifted or swung through the air by the hand or wrist.

Fortunately, gaining lost range of motion, strength, and coordination goes quickly after suffering from nursemaid’s elbow. You will notice improvements in your child’s elbow function even after just a few treatments with your Physical Therapist at Atlas Physical Therapy. If your child’s pain continues longer than it should or therapy is not progressing as your Physical Therapist at Atlas Physical Therapy would expect, we will ask you to follow-up with your child’s doctor to confirm that there are no complications that may be impeding your child’s recovery. Generally, however, children respond very well to the Physical Therapy we provide at Atlas Physical Therapy. Under the supervision of one of our Physical Therapists your child should be back to the daily activities they enjoy in no time.

Atlas Physical Therapy provides services for Physical Therapy in Congress Park, Denver Downtown, Central Park, and Highlands Area.

Portions of this document copyright MMG, LLC.