Nursemaid's Elbow: Restricted Movements
In a child with nursemaid's elbow, supination and flexion of the forearm are the primary restricted movements, with the child typically holding the affected arm in a pronated, slightly flexed position close to the body and refusing to use it. 1, 2, 3
Clinical Presentation of Movement Restriction
The characteristic presentation includes:
- The child holds the arm motionless at the side in a pronated (palm-down) and slightly flexed position 2, 3
- Active supination (turning the palm upward) is avoided or impossible 1, 2
- Flexion at the elbow is limited due to pain and mechanical obstruction from the subluxed radial head 1, 3
- The child refuses to use the affected arm for reaching, grasping, or any functional activities 2, 3
Key Distinguishing Features
Important clinical characteristics that help identify this injury pattern:
- No obvious swelling or deformity is visible on inspection 2
- The child experiences minimal pain at rest but avoids movement 2, 3
- Passive movement attempts are resisted, though not with severe pain typical of fractures 2
Mechanism Explaining the Restriction
The movement restriction occurs because:
- Sudden longitudinal traction on the extended, pronated arm causes the radial head to slip through the annular ligament 1, 2, 4
- The entrapped annular ligament in the radiocapitellar joint mechanically blocks supination and full flexion 5, 3
- The child instinctively maintains the arm in the position of least discomfort (pronation with slight flexion) 2, 3
Clinical Pitfall to Avoid
Do not assume a fracture has been excluded simply because there is no swelling or severe pain—if reduction maneuvers fail after two attempts, splint the arm and refer for imaging to rule out fracture. 2 The typical presentation of nursemaid's elbow (minimal pain, no deformity, refusal to move the arm) can usually be distinguished from fracture based on history and examination alone, but atypical presentations warrant further evaluation. 5, 2