Anatomy in Action Series: Nursemaid's Elbow
Educational articles designed to help CAs understand the underlying anatomy and physiology of conditions presenting to the chiropractic office.
Extremity pain is no stranger to the chiropractic office. DCs very commonly see shoulders, elbows, wrists, knees, and feet.
This article will focus on a particular condition of the elbow joint called nursemaid's elbow, which is most commonly seen in children.
Anatomy of the Elbow
The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm, which allows the hand to be moved toward and away from the body. These bones are joined by cartilage, tendon, and ligament. The annular ligament, which surrounds the head of the radius bone where it joins with the humerus, is of special note.
Also, note that although the superior radioulnar joint shares a joint capsule with the elbow joint, it plays no real functional role at the elbow.
The elbow region includes prominent landmarks such as the olecranon (the bony prominence at the very tip of the elbow), the elbow pit, and the lateral and medial épicondyles. The name for the elbow in Latin is cubitus, and so the word cubital is used with some elbow-related terms, as in cubital nodes, for example.
igThis condition con be readily seen on visual inspection and should be suspected if there is a lump present on the lateral
part of the arm.99
Nursemaid's elbow basically refers to a subluxation of the radial head. The head will actually be pulled from, or slip, out of the annular ligament that secures it to the humerus bone. This condition can be readily seen on visual inspection and should be suspected if there is a lump present on the lateral part of the arm. The lump is caused by the displaced head. It can also be seen on radiograph.
In radial head subluxation, there strangely may be little complaint of local pain. The patient usually reports pain in the proximal forearm. Radial head subluxation is a common pediatric presentation generally occurring between the ages of one and three years, although it can happen anytime between six months of age and seven years.
After age three, however, children's joints and ligaments tend to gradually grow stronger, making radial head subluxation less likely to occur. The distal attachment of the annular ligament coveringthe radial head is weaker in children than in adults, allowing it to be more easily torn. An older child will usually point to the dorsal aspect of the proximal forearm when asked where it hurts.
This may mislead one to suspect a buckle fracture of the proximal radius. There is no tear in the soft tissue, most likely due to the pliability of young connective tissues.
The classic mechanism of injury is longitudinal traction on the arm with the wrist in pronation, as occurs when the child is lifted up by the wrist. Historically, it received its name because old-time nannies would pull up on the arms of their small charges while dragging them through town, and the angle was just right to displace the bone. Unsuspecting parents and older children can also inadvertently cause the condition when swinging a child between them. Rough play on a swing set could provide a similar result.
There are instances, unfortunately, when a nursemaid's elbow can be a clue pointing to child abuse.
Although this won't be the norm, as mandatory reporters, chiropractors must be cognizant of this and be mindful about looking for other indications of abuse or neglect in a child, and then proceed accordingly if it appears foul play is at hand.
With a radial head subluxation the signs, symptoms, and causation may be misleading. They include but are not limited to the following points to be aware of:
• No pinpoint pain at the radial head, but rather pain on the general proximal forearm.
• The child stops using the arm, which is held in flexion and pronated.
• Minimal swelling.
• All movements are permitted except supination.
• Caused by longitudinal traction with the wrist in pronation. Although in a series, only 51% of patients were reported to have this mechanism, with 22% reporting falls, and patients younger than six months of age noted to have the injury after rolling over in bed.
Management of Nursemaid's Elbow
To resolve the problem, the affected arm is moved in a way that causes the joint to move back (adjust) into a normal position. The two main methods
The classic mechanism of injury is longitudinal traction on the arm with the wrist in pronation, as occurs when the child is lifted up by the wrist.33
are hyperpronation and a combination of supination and flexion. In one study, hyperpronation required fewer attempts, was more successful initially, and was often successful when supination/flexion failed. The patient may wear a brace to limit motion while the damaged ligament regains its strength. Hot/cold therapy to usher blood in and out of the ligamentous tissue and promote healing may also be utilized. Of course, lifestyle changes must also be addressed so that all people in contact with the child will avoid putting the arm back into a vulnerable position.
Education Fosters Understanding
An understanding of anatomy and clinical applicability helps all health-office employees better communicate with patients and provide care more safely. Online training programs in particular make high-quality training affordable and convenient, and can be taken any time of day. At CCCAonline.com, learners can
ííln one study' hyperpronation required fewer attempts, was more successful initially, and was often successful when supination/flexion failed.33
engage in a streamlined 24-hour training program that meets or exceeds FCLB guidelines in every area of study and fulfill the training requirements needed for the national examination!
DCs will often pay for their employees to train. Full price for this training is an affordable $339 for the entire 24-hour program. CCCAonline.com also has a special discount available for you! If you are receiving this article through The American Chiropractor magazine, use AMCHIRO as your discount code. When you enter this code during the registration process, it will automatically provide a $15 discount off the regular price of the program. This is the program that gives
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Learners can expect text, images/schematics, dynamic video lectures, and robust, customized, experiential interactivities in a thorough 19-module program. It also includes an extensive note-packet of nearly 200 pages that can be downloaded, printed, and studied off-line. Learners work at their own pace and can conveniently take programming around work hours to avoid disruption in the office. Questions? Visit our website or send us an email at CCCAonline@ gmail.com
H Laurie Mueller, BA, DC, CFMP served in private practice in San Diego, California. She was the postgraduate director at Palmer College from 2000 to 2010; served as the ACC postgraduate subcommittee chair for six years; peer-reviewed for the Research Agenda Conference; and wrote the informal role determination study that aided in the development of FCLB ’s guidelines for chiropractic assistants. Dr. Mueller currently works as a private eLearning consultant with a focus on healthcare topics and functional medicine through her company, Impact Writing Solutions, and the subsidiary, CCCAonline.com. She is a clinician, an educator, and an expert in online educational pedagogy.