Nursemaid's elbow presents in a very specific way: the parent brings in a toddler who is holding one arm slightly bent, hanging at their side, and refusing to use it. There was a moment — usually a pull, a swing, or a stumble — and since then the arm has been like that. There is no bruising, no deformity, no swelling. The child is distressed about moving the arm but otherwise fairly comfortable.
This is a common presentation, and once seen and treated, it is memorable. The reduction manoeuvre, correctly performed, resolves the injury in seconds. The child goes from refusing to move the arm to using it normally before the consultation is over. Parents who have seen this once tend to bring children back for the same thing the next time it happens, which it often does.
Healthbooq (healthbooq.com) covers common injuries and orthopaedic issues in toddlers.
What Happens to the Elbow
The radial head is the top end of the radius bone in the forearm, which articulates with the humerus (upper arm bone) and also rotates within the annular ligament. In children under about five years, the radial head is relatively small and the annular ligament relatively lax, making it possible for a sudden longitudinal traction force on the forearm to pull the radial head partially out from under the annular ligament. The annular ligament then becomes interposed in the radiohumeral joint.
This is not a true dislocation — the bone has not completely displaced from the joint — which is why "subluxation" (partial displacement) or "pulled elbow" are more precise terms. There is no joint disruption, no bony injury, and no ligamentous tear. The injury resolves completely with reduction.
After around age five to six, the radial head is larger and better contained, and the ligament is stronger, so the injury is much less common.
Mechanism
The classic mechanism is a sudden longitudinal traction force on the outstretched arm: swinging a child by one hand or by the wrists, pulling a child up suddenly to prevent a fall, pulling a child along by one hand. Sometimes the mechanism is less clear — a fall onto the outstretched arm, or a child reaching under a bed. Parents often feel guilty thinking they have hurt the child.
Presentation
The child holds the affected arm in slight elbow flexion, slightly pronated (forearm turned down), and refuses to use it. Attempting to supinate the forearm (turn it palm-up) causes distress. The elbow is not visibly swollen or deformed. There is tenderness over the lateral elbow (radial head area) in some cases, but often there is very little to find.
X-ray
X-ray is generally not required unless the history and examination suggest a bony fracture — an unusual mechanism, significant swelling or bruising, or point tenderness over the bone rather than the radial head area. In a typical pulled elbow with a classic history, X-ray is normal and exposes the child to unnecessary radiation.
Reduction
Two reduction manoeuvres are in common use:
Supination-flexion technique: the examiner holds the child's elbow with one hand, thumb over the radial head, and with the other hand supinates the forearm fully (turning it palm-up) then flexes the elbow. A click or "clunk" is felt over the radial head as the ligament is freed and the radial head returns to its normal position.
Hyperpronation technique: the forearm is pronated fully (turned palm-down) with the elbow at 90 degrees. A click is felt and the joint is reduced. Several studies and a meta-analysis (Bexkens et al., Annals of Emergency Medicine 2017) found hyperpronation slightly more effective than supination-flexion, particularly in children over three.
After successful reduction, the child typically moves the arm normally within five to fifteen minutes as the initial discomfort settles. If the arm is still not being used after fifteen minutes, a second attempt at reduction can be made, or X-ray considered.
After Treatment
No specific treatment is required after successful reduction. Normal activity can be resumed immediately. There is no splinting or casting.
Recurrence is common — approximately 20 to 30 per cent of children have a second episode, usually within a year. Parents should be advised to avoid pulling the child by the hand or wrists and to lift under the armpits.
Key Takeaways
Nursemaid's elbow (pulled elbow, radial head subluxation) is one of the most common orthopaedic injuries in young children, affecting primarily those aged one to four years. It occurs when a longitudinal pull on the arm — typically when a child is swung by the hand or pulled to prevent them falling — causes the radial head to slip partially out from under the annular ligament. The child holds the arm limp and slightly bent and refuses to use it. There is no bruising, swelling, or obvious deformity. Reduction by a doctor or nurse (supination-flexion or hyperpronation manoeuvre) produces immediate relief and full use of the arm returns within minutes.
