As I settled in to take the history of my next patient, the nurse knocked on the door and apologized for interrupting me. "Before you get started, there’s an emergency here and I thought you might want to see him first", she said with some urgency in her voice. Before I could even ask what was wrong, she went on, "It’s a little boy. The parents think that he dislocated his shoulder". The mother of the patient I just started to see motioned with an approving nod as if to tell me to go tend to the boy.
When I walked into the treatment room I observed both parents with somber and worried looks on their faces. Mom had obviously been crying and dad was holding the little boy in his lap. Little Jake, who is two years old, was sitting motionless in dad’s lap with his left shoulder somewhat lowered when compared to the right shoulder--his elbow was bent at 90 degrees and he held his arm across his abdomen as if to protect it. He would not let anyone get near his arm.
Before I could even get in a "hello", both parents simultaneously started to tell me what had happened. After everyone calmed down, the history went as follows. They were walking down the sidewalk, Jake in the middle with a parent on each side. They were holding Jake’s hands and every five or so feet, they would count one, two and three, and then lift little Jake up in the air. He got a big kick out of this and would laugh uncontrollably. All of a sudden, after the count of three, Jake let out a shrill scream as they lifted him into the air. He immediately started to cry, and would not move his left arm. They were certain that they had pulled his shoulder out of its socket.
As I clarified the history, I closely watched Jake who was sitting comfortably in dad’s lap. Certainly if he had dislocated his shoulder, he would not be so comfortable. The parents reiterated that there was absolutely no direct trauma to the arm, or that Jake had not fallen on his arm.
I told them that I thought that the problem was actually in Jake’s elbow, that this is a common childhood injury, and that Jake would be back to normal in a matter of seconds. I told dad to keep Jake in his lap as I scooted my chair in front of them. I gently felt for Jake’s pulse in his injured arm and it was strong and steady. I could not see any swelling or discoloration of his arm either. Since the injury was observed by both parents and there was no history of direct trauma to the arm, I felt comfortable in reducing Jake’s dislocated elbow without obtaining x-rays. With Jake facing me, I put my left hand behind Jake’s left elbow to support it, and I took his left hand and wrist with my right hand. He started to cry before I actually touched his arm and I could tell that this made dad very nervous. In a slow, gentle and steady motion, I simultaneously rolled his forearm outward (as if to turn his palm upward) and straightened his elbow so his arm was straight. I then bent his elbow upwards like he was doing a curl. I immediately felt a pop and knew that his elbow was reduced.
Jake was still crying and both parents looked perplexed when I said that he would be fine. I told them to watch Jake as I left the room to get him some stickers. When I returned Jake was playing and laughing as he moved both arms as if nothing had happened. I then proceeded to tell them about Jake’s subluxed radial head, or nursemaid’s elbow.
This is a very common injury in children under the age of five years. The force that causes this is a pulling of the arm. It often happens when someone swings the child while holding their hand, or more commonly if someone is walking with a child, holding their hand, and the child trips and falls. By reflex the adult pulls up on the child’s arm to prevent them from falling down. This pulling force is sufficient to dislocate the elbow. If the child falls on his arm, sustains any direct trauma to the arm, or sustains an unwitnessed injury, then one must be certain that there is no fracture before entertaining a diagnosis of a dislocated elbow. This most definitely requires x-rays.
There are two bones in the forearm, the radius and the ulna. They are attached near the elbow by a fibrous ligament, the annular ligament, which encircles the radius and attaches it to the ulna to stabilize the two bones. When the arm is pulled as described above, the radius is pulled away from the elbow and the annular ligament is torn in the process. The torn portion dislocates, or slips, into the elbow joint where it becomes trapped. The maneuver I performed on little Jake restores the ligament to it’s proper anatomical position and resolves the problem in well over 90% of the cases. Once the elbow is reduced it is a resolved issue and requires no further treatment. Rarely do the children complain of any pain afterwards. Often time the children are so used to the arm hurting, they will refuse to use the arm in anticipation of it hurting even though it has been reduced. Once they are distracted or can be made to forget about their arm, they use it as if nothing had happened. That’s why I left the room to get the stickers.
An exception to this is when the elbow has been subluxed for over 10 hours. In this case, the muscles around the elbow joint will go into spasm because of the inflammation. These elbows are more difficult to reduce, and afterwards the arm may be sore for a day or so.
A subluxed radial head is rare beyond the age of five years because the annular ligament becomes very strong by that age and is very unlikely to be torn by simple pulling forces on the arm. This is a benign condition that is frequently seen in pediatrics. It is one of the few times that a doctor can make a diagnosis, treat the problem and have instantaneous results in a matter of seconds.