Nursemaid’s Elbow - What every caretaker should know
What is Nursemaid’s Elbow?
There are two bones in the forearm: the radius and the ulna. The radius essentially sits within part of the ulna and is held in place by a ligament. Unfortunately, it is NOT that stable of a joint, especially in young children. That is where Nursemaid’s elbow comes in!
If a child is pulled by their hand and they aren’t activating muscles in preparation, the radial head can dislocate from the joint above. This injury is called nursemaid’s elbow, as years ago child care providers were blamed for the injury when pulling children by the hands. Unfortunately, once this injury happens, re-injury rates are often very high.
Nursemaid’s elbow is considered most commonly to occur to children between the ages of 0-4 (though it can happen beyond that). This happens because ligaments are more lax (looser) in children, and muscular strength isn’t quite there yet to compensate and contribute to stability. Side note- this is where weight bearing through hands and really working those muscles during tummy time and crawling is important!
Some signs and symptoms of nursemaid’s elbow include:
Sudden decrease in use of their arm
Crying, signs of pain (wrist pain is a common complaint*!)
An audible noise or pop when someone tugged on a child’s hand or arm
There is NOT usually obvious swelling or deformity
How do you decrease the risk of Nursemaid’s elbow occurring?
Avoid swinging your children by their hands
Avoid pulling your child into sitting by their hands
Use caution when dressing – avoid pulling hands through long sleeves or jacket)
Avoid picking children up by their hands (support under their armpits around their trunk)
Use care when siblings are playing
Use caution when holding onto your children's hands (crossing the street)
Avoid holding hands when learning to walk (if you are holding on to their hands and they fall, the force can cause it to occur)
As an aside, please do not worry about holding your child! There is an immense difference between holding their hand and they are ACTIVELY holding back, versus holding their hand while they are resisting and/or trying to pull their hand away. That is what may contribute to a potential injury, HOWEVER please know, safety is always the top priority and you know your child best! Nursemaid’s elbow is just something to be mindful of, and simple tips to modify everyday activities can make a big difference in avoiding the injury!
Quick Tip! Avoid pulling on hands during dressing- Instead pull/push the CLOTHING, rather than their hand or arm. Added bonus - this encourages them to help push their arm through, which encourages independence in dressing! Same when removing, aim to grab only the clothing when possible. For a visual of this practice, watch my instagram reel here.
What about pulling to sit/chin tuck practice?
The reality is, I know many amazing clinicians who test it from the arms, and I respect them! For me personally, I feel comfortable in assessing the same skill (chin tuck) in a way that does not involve using their hands, so that is what I do! Regardless, the key is that the child has to be actively contracting their muscles. If they are passive and we are pulling on their hands, there is a risk that this injury could occur. As with everything when it comes to your little one, the choice is yours, but hopefully this information helps you make a decision that feels best!
For a full visual on how a child’s muscles are activated during the pull to sit test, how I modify it to avoid hands, and isolates neck muscles more in my opinion - check out this Instagram Reel.
Lastly- let’s address the elephant in the room!
One of the most common questions I get in regards to nursemaid's elbow is- what about swinging by the hands between two adults?! (as shown in this Instagram video)
To avoid being labeled a “fun sucker”, hah!, let me share how I prefer to do a similar activity with my little one, and why!
The crucial part is breaking down PASSIVE versus ACTIVE muscles again.
If you watch the first part of this reel, the child is PASSIVE. His muscles are not actively contracting to stabilize that joint, and he is essentially hanging by his hands with a relatively strong force used to lift him. This becomes problematic because as mentioned above, the joint involved in nursemaid's elbow is relatively unstable, and even more so when under 4 years of age. Essentially, there isn’t much providing stability to the joint OUTSIDE of muscles being active, so setting up situations where that is able to occur are key! Muscles ACTIVE = MORE stability to the joint and REDUCED risk of a nursemaid’s elbow occurring.
Now, compare that to the second part of the clip. See how she is much more ACTIVE? SHE is holding onto OUR hands, rather than us gripping hers, and then SHE is lifting her feet off the ground using her muscles. If she can no longer sustain the position, her feet drop down. It’s a similar idea to a child on monkey bars- if they can’t hold themselves, they drop down!
Being ACTIVE versus PASSIVE greatly reduces the risk of nursemaid's elbow, and is one of the biggest tips I have for you and your little ones!
Suspect nursemaid’s elbow? Take your child in to be seen by a medical professional asap! Though it can relocate on it’s own, it’s always best to have them thoroughly assessed. And THANKFULLY, it is fairly easy & quick to set the radius back into place, and the child almost always instantly has pain resolution!
I know any injury is scary when it comes to our little ones, and nursemaid’s elbow is no different, BUT there are ways to reduce risk of occurrence, which is GREAT! Knowledge is power, and I hope this blog helped you feel just that!
Want More?
For developmental questions, tips and guidance related to milestones about tummy time, rolling & sitting, crawling and walking, check out KC’s developmental Masterclasses linked here.
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KC is a pediatric doctor of physical therapy, wife and mom of three! She has spent her career working with children and young adults of all ability levels, and currently specializes in birth to three years.
