What could cause this pain in her arm? She didn’t fall or bump it. But she won’t move it.

 

The office was just about to close when the phone rang and a frantic mom was calling about her 2 ½-year-old daughter who had injured her arm. She wanted to know if she should dare go to the emergency room. She was also worried about the Covid-19 pandemic and sitting in an ER waiting room with the potential exposure to the virus.  

Our front office person gave me the phone and I asked mom exactly what had happened. She said that her mother, the patient’s grandmother,had been watching her for a couple of hours in the afternoon.When mom returned from her errands the grandmother said that Annie had somehow hurt her arm. She didn’t know exactly how or why because she had never let her out of her sight. Grandma felt horrible about it but was perplexed as to what had happened. She wasn’t sure if it was Annie’s wrist or shoulder, but the child held her arm at her side and refused to bend it. She would resist and cry if anyone tried to move her arm.
 

The one thing that grandmother did recall was that Annie had been climbing up a little slide in the back yard with grandmother holding her hand. Annie lost her footing and fell down.

 

Grandmother instinctively held her arm up to “catch her” but was insistent that the child never fell or landed on her arm. She said she didn’t think much of it,but shortly thereafter Annie seemed quiet and no longer wanted to play. Mom came home within 15 minutes and they felt that something was wrong.They weren’t sure if it was her shoulder or her wrist. That is when mom called our office.
 

Given the history I told mom to head right over to the office and we would wait for her. When they arrived Annie seemed calm and in no distress.

 

I had her sit in mom’s lap and asked if I could “see her muscles” in the uninjured right arm. She nodded yes and I straightened her arm in front of her down by her waist. Then I slowly rotated her wrist laterally so her palm faced me. Then I simultaneously bent her arm as if she were doing a curl in weightlifting. Jokingly I said, “Boy, look at those big muscles,” and she smiled. Without giving her time to think about it, I said,”Now let’scheck the other arm,” doing the same maneuver on the left arm. As I began to do the procedure she started to resist and got a worried look on her face .As I rotated her arm out and started to flex the elbow, I felt a little pop. I knew that the dislocated elbow had been reduced.  

Annie had what is called a nursemaids elbow in the lay vernacular, but more accurately it is known as a subluxation of the head of the radius. It is a common injury in children between the ages of 1 and 4 years. The radius is the bone of the forearm that is on the side of the thumb. The two bones of the forearm, the radius and the ulna join the humerus at the elbow. The radius has an annular ligament at the end near the elbow that secures it in place. In a young child the ligament is more elastic and loose. When a child’s arm is subjected to a pulling force the “head’ of the radius can slip out of the ligament that now gets trapped. That is what causes the pain and refusal to move the arm. It is easily reduced by the maneuver I described above, and there should be immediate relief and arm usage.
 

The usual forces that cause nursemaids elbow are when one is holding a child’s arm and the child falls you quickly pull the arm up to prevent the fall. Or if a person is “swinging” the child by the arms, or even if children are wrestling and the arm gets pulled.

 

There should be NO history of trauma or injury. It is also imperative that a reliable person actually sees the forces that caused the problem and is 100% certain there was NO trauma. If I have any question about what happened or it was not witnessed, I wouldn’t touch the arm without x-rays. If there was any swelling or bruisingagain I would do nothing without x-rays.
 

Children rarely have nursemaids elbow after 4-5 years of age.

 

They can recur if those forces described above occur. Once the elbow is reduced successfully (the physician feels a tiny pop), it is not uncommon for the child to refuse to use her arm for fear that it will still hurt. They almost have to be distracted. Once Annie’s arm was reduced her mom asked her to move it and bend her elbow. But she wasn’t having it at all. I told mom that I’d be right back and left the room for a few minutes and got some stickers. When I came back I had her sit in mom’s lap.Standing over her I presented her with the stickers but in such a manner that she would have to reach up for them. She snagged them up as if nothing had ever happened.