Pulled Elbow (Nursemaid's Elbow) in a Toddler

What causes nursemaid's elbow

Nursemaid's elbow — now more precisely described as annular ligament displacement — occurs when the radius (one of the two forearm bones) slips partially out from under the annular ligament at the elbow 2Ref 2Paluch LK (2024).Nursemaid's Elbow: Radial Head Subluxation Injuries in Children.2024 clinical review of nursemaid's elbow (radial head subluxation): caused by pulling injury to the arm; diagnosis is clinical; reduction via manipulative technique restores function with multiple approaches available; imaging can confirm diagnosis or verify successful reduction when needed. In young children, this ligament is more elastic and not yet as firmly developed as in older children, which is why this injury is uncommon after age 5 or 6 1Ref 1American Academy of Pediatrics (2021).Nursemaid's Elbow.AAP guidance on nursemaid's elbow: most common in children under 4, typically caused by arm pulling or swinging; symptoms include arm hanging at the side with elbow slightly bent; a provider can immediately reduce it with rapid relief; prevention includes lifting under the arms, not by hands or wrists — last updated June 2, 2021.

Common mechanisms: - A caregiver lifts or swings a child by the wrists or hands - A child trips and is caught by the hand - A child falls and the arm is pulled or twisted - Rolling over onto the arm in a certain position

Sometimes parents report no obvious pull or yank — the joint can slip during apparently ordinary activity. This can make parents doubt themselves, but the injury does not require a forceful yank.

What it looks like

The classic picture of nursemaid's elbow is recognizable once a parent has seen it 1Ref 1American Academy of Pediatrics (2021).Nursemaid's Elbow.AAP guidance on nursemaid's elbow: most common in children under 4, typically caused by arm pulling or swinging; symptoms include arm hanging at the side with elbow slightly bent; a provider can immediately reduce it with rapid relief; prevention includes lifting under the arms, not by hands or wrists — last updated June 2, 20212Ref 2Paluch LK (2024).Nursemaid's Elbow: Radial Head Subluxation Injuries in Children.2024 clinical review of nursemaid's elbow (radial head subluxation): caused by pulling injury to the arm; diagnosis is clinical; reduction via manipulative technique restores function with multiple approaches available; imaging can confirm diagnosis or verify successful reduction when needed:

• The child cries or becomes immediately upset after the arm was pulled or an awkward movement occurred
• The arm hangs at the side with the elbow slightly bent and the palm facing downward or backward (pronated) — the child avoids turning the palm upward
• The child will not lift the arm, reach for objects, or allow the elbow to be bent
• When not being touched, the child may be relatively calm or distracted; pain increases sharply with any attempt to move the elbow
• There is no visible swelling or bruising — the elbow looks completely normal on the outside

The absence of swelling is an important feature that helps distinguish this from a fracture. If there is visible swelling, a fracture should be considered.

What happens at the doctor's office

A provider who is familiar with this injury will typically diagnose it based on the history and physical appearance of the arm — no X-ray is needed in the classic presentation 2Ref 2Paluch LK (2024).Nursemaid's Elbow: Radial Head Subluxation Injuries in Children.2024 clinical review of nursemaid's elbow (radial head subluxation): caused by pulling injury to the arm; diagnosis is clinical; reduction via manipulative technique restores function with multiple approaches available; imaging can confirm diagnosis or verify successful reduction when needed. The reduction (maneuver to guide the bone back into place) takes only a few seconds and involves a specific movement of the forearm and elbow.

Most children experience immediate or near-immediate relief — within minutes to an hour, the child begins moving the arm again, reaching for objects, and the episode is over 1Ref 1American Academy of Pediatrics (2021).Nursemaid's Elbow.AAP guidance on nursemaid's elbow: most common in children under 4, typically caused by arm pulling or swinging; symptoms include arm hanging at the side with elbow slightly bent; a provider can immediately reduce it with rapid relief; prevention includes lifting under the arms, not by hands or wrists — last updated June 2, 2021. It can be startling for parents to see how complete the recovery is after a brief maneuver.

X-rays may be obtained if there is swelling, if the history is unusual, if the child is older (over 5), or if the reduction maneuver does not work, to rule out a fracture 2Ref 2Paluch LK (2024).Nursemaid's Elbow: Radial Head Subluxation Injuries in Children.2024 clinical review of nursemaid's elbow (radial head subluxation): caused by pulling injury to the arm; diagnosis is clinical; reduction via manipulative technique restores function with multiple approaches available; imaging can confirm diagnosis or verify successful reduction when needed.

Preventing a recurrence

Nursemaid's elbow tends to recur — a child who has had one episode is more likely to have another until the ligament matures (typically by age 5–6) 1Ref 1American Academy of Pediatrics (2021).Nursemaid's Elbow.AAP guidance on nursemaid's elbow: most common in children under 4, typically caused by arm pulling or swinging; symptoms include arm hanging at the side with elbow slightly bent; a provider can immediately reduce it with rapid relief; prevention includes lifting under the arms, not by hands or wrists — last updated June 2, 2021. To reduce the risk:

• Avoid lifting children by the wrists or hands — lift under the armpits instead 1Ref 1American Academy of Pediatrics (2021).Nursemaid's Elbow.AAP guidance on nursemaid's elbow: most common in children under 4, typically caused by arm pulling or swinging; symptoms include arm hanging at the side with elbow slightly bent; a provider can immediately reduce it with rapid relief; prevention includes lifting under the arms, not by hands or wrists — last updated June 2, 2021
• Avoid swinging a toddler by the arms — swing them by the trunk 1Ref 1American Academy of Pediatrics (2021).Nursemaid's Elbow.AAP guidance on nursemaid's elbow: most common in children under 4, typically caused by arm pulling or swinging; symptoms include arm hanging at the side with elbow slightly bent; a provider can immediately reduce it with rapid relief; prevention includes lifting under the arms, not by hands or wrists — last updated June 2, 2021
• When helping a child up stairs or curbs, hold by the forearm close to the elbow rather than by the hand
• If a caregiver knows the child has had prior episodes, the child's provider can sometimes demonstrate the reduction technique for future episodes — though this should only be done by someone trained and when the presentation is clearly typical

Once children are past approximately age 5–6 and the ligament has matured, the risk drops substantially.