Elbow Woes

This week’s guest columnist is Dr. Tasia Bradley, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

I was two years-old.  “Pick me up! Pick me up!” I yell to my sister. She grabs my hands, begins whirling me around, and up into the sky I go.  “Faster! Faster!”  Suddenly a pain in my left elbow.  I begin to shriek as my sister lets me down, a puzzled look on her face, what did she do?  Now Mom’s worried, she doesn’t know what happened either.  On my first trip to the Emergency Department, the staff’s all smiles, no big deal, just a dislocation.  1…2..3.. back in place.  Soon I’m running around again, but no more flying in the sky.

“Nursemaid’s Elbow” is an occasional event in toddlers, where a bone in the elbow gets dislocated. The forearm has two side-by-side bones, the radius and the ulna.  Their ends near the elbow are held together by a rubber-band called the annular ligament. In some kids that ligament is weak, and the radial end can be pulled out of that loop by traction. Traction like being whirled around like me above, or having the hand jerked to hurry a slow toddler along.  Sometimes it happens when a parent is trying to get a shirt off, tugging away at that long sleeve, and pop!

When children dislocate their radius, they cry at first, but then settle down.  It looks benign- no swelling like with a broken bone, and kids often start playing again.  Except that they’ve stopped using that elbow, letting it hang by their side, and do everything with the other arm.  When parents bring them in, no x-rays necessary.  If the story’s right (“Pulled on the wrist, eh?”), it’s a simple maneuver to put it in place. The elbow clicks like you’ve cracked a knuckle, a brief squawk from the child, and in a few minutes she’ll give you a high-five. Fixed!

To avoid this injury, of course, no tugging on hands and wrists. Pick up infants and toddlers under their armpits.  But kids like being swung around, and they also can dislocate when wrestling or falling just so. When they pop that elbow, bring ‘em in. The good news: kids prone to Nursemaid’s Elbows develop stronger annular ligaments and stop dislocating by age 5.

Fast forward from 2 year-old Tasia above, to 1994. I’m on the playground at Boudreaux Elementary in Gretna, climbing the ladder to the monkey bars. Grab one bar, swing to  the next, and the next, and….I’m falling through the air and land on my right arm.  I’m crying, my elbow hurts so much. I went to my teacher, who wasn’t worried because there wasn’t any swelling, and by the end of the day I was using it again.  No Emergency Department visit this time, but I’ve never been on monkey bars since. Just looking at them makes me break out in a sweat.

Sometimes though, kids end this scenario with a swollen elbow that just won’t stop hurting. Besides being vulnerable to dislocations as we discussed above, kids’ elbows are susceptible to fractures.  The bone at the elbow end of the humerus (the upper arm bone) is thin.  When kids land on their elbow, or impact on their outstretched hand, that bone end can crack.  In fact, 70% of these fractures occur when the child falls and puts his hand out to brace himself. The force is transmitted through the forearm and snaps that vulnerable spot.

These injuries are more obviously bad than the Nursemaid’s elbow from above. The elbow is swollen and sometimes blue from internal bruising, and it really hurts.  These need to be seen in the ER for x-rays, pain medicine, and treatment.  Sometimes all that’s needed is a cast to hold the broken elbow still and protect it while it heals, usually 4-6 weeks. In some unlucky kids, however, the end of the humerus is cracked all the way through and shifted. These need surgery to pin that thin bone end back in place.

Finally, let’s briefly talk about the word “fracture.”  Occasionally, a parent will be discussing their kid’s bone injury, and ask “is it broken or is it fractured?”  This question puzzles us, since a fractured bone IS broken. It’s like asking “is the sky blue, or is it azure?”  Fracture is just a fancy word for broken, and either way, it needs treatment, usually a cast, but sometimes surgery.  Hopefully when your kid hurts their elbow, it will just be sprained like mine was, and get better in a matter of hours.  But if it’s swollen and really painful, come on in!



Oh no! I think I broke my kid’s arm!

This week’s guest columnist is Dr. Michelle Taylor, a family practice resident at University Health Center here in Lafayette.

2 year-old Lily was playing around the pool.  You go to move her from the edge and grab her hand.  She slips in a puddle and her arm gets tugged.  She bursts into tears and now keeps her arm at her side and doesn’t move it.  Now you’re crying too: “What did I do to my baby?  Did I break her arm?”

Thankfully, you didn’t.  Lily has what’s called a “Nursemaid’s elbow.”  Nursemaid’s elbow is a common injury of early childhood, in infants, toddlers, and preschoolers.

What exactly happens?  You have two bones in your forearm, the radius and the ulna. They lie side by side and their upper ends are part of your elbow joint. Those ends are bound together by a ligament, like a rubber band holding two sticks together.  In some kids that ligament is weak and the radius end slips out when tugged.

Actions that cause a Nursemaid’s elbow include 1) jerking a child by the wrist.  Even something as minor as pulling a child’s arm through a sleeve can cause the radial head to slip. 2) Pulling a child up by the hands.  Lifting a child under the armpits is safest. 3) Swinging a child around by the arms.  While lots of kids love this, save it for when they are older than 4 years.  4) Falling over.  Sometimes if a baby is sitting up and flops over on her side, her arm can be pinned under her so that the radial head clicks out.

How do you know if your child has a Nursemaid’s elbow?  First of course, the arm is tugged like above.  When it happens, the parents usually feel a pop in the child’s arm, often in the wrist.  Since they are holding the wrist, they think that’s where the injury is. However, the pop happens in the elbow and the parent feels the pop transmitted down the child’s radius to the wrist.

The child cries at the time of dislocation, but often settles down and acts fine as long as the elbow doesn’t move.  He will walk around with his arm hanging by his side.  Only when he forgets and tries to use that elbow will he whimper.  There is no swelling.

How do you know if the elbow is broken, not just a Nursemaid’s elbow like above? Let’s change Lily’s story from above.  Instead of having her arm tugged, say she was running around the pool, slipped, and fell on her elbow.  She cries and cries and doesn’t settle down and the elbow swells.  Then it may be cracked.

Sometimes with toddlers, we don’t know how they got hurt.  Say Lily was playing in her room with 3 year-old cousin Elliot.  You hear a cry and Lily comes running out holding her arm.  Did Elliot pull on the arm and cause a nursemaid’s elbow, or did she fall off the bed and break it?  Elliot and Lily can’t say- they don’t have the words yet .

Those cases we have to x-ray.  Broken elbows are often swollen because the crack in the bone bleeds within the joint, but not always!  If we don’t have a clear story that the child’s elbow was only pulled on and not fallen on, a cracked bone is possible.  Broken elbows need to be casted so that they will hold still for the month or two it takes for the bone to heal.

However, if it is a nursemaid’s elbow with a clear story of the arm simply being pulled on, no casting or xrays are necessary- the doctor fixes it right away. We have the child sit on mom’s lap, perform a gentle twisting and flexing maneuver, and feel the radius pop back in place.  The child cries, but usually settles down and within 5 minutes is using the arm normally.

You are not a bad parent if your child has a nursemaid’s elbow.  You can’t know if your child has loose ligaments in the elbows until it happens.  Kids who get it may get it again- those ligaments don’t tighten up until age 4 or 5.  Remember to avoid tugging your child’s arm or swinging them around.  And if that elbow pops out again, bring them in and we’ll pop it right back.