Nursemaid’s elbow is a common injury in young children that causes pain when moving the arm. It occurs when the radius, one of the two forearm bones, partly slips out of its usual position at the elbow. Part of a nearby ligament (the annular ligament) can slip into the joint and get caught, which limits movement and makes it painful to bend or rotate the forearm. Children affected by nursemaid’s elbow often avoid using the injured arm and may keep it close to their body.

In the United States, nursemaid’s elbow is among the most common elbow injuries in children, affecting about 20,000 each year. It is seen most often in young children between one and four years old, but it can occur from six months up to age seven. The injury can occur when a parent or other caregiver pulls a child’s arm to avoid danger or help them up the stairs, which is why it is called nursemaid’s elbow. Girls are slightly more likely to be affected than boys, and the left arm is injured more often than the right. The injury becomes rare after age five, as the ligaments around the elbow strengthen with age.

Nursemaid’s elbow can be treated quickly and effectively in a doctor’s office. After treatment, most children can return to normal activities within minutes to hours.

Nursemaid’s elbow—also called “pulled elbow,” annular ligament displacement, or radial head subluxation—is a partial dislocation of the elbow joint.

A joint is where two or more bones meet. At the elbow joint, the humerus, or upper arm bone, meets the radius and the ulna (the two bones of the forearm). The radius is located on the thumb side of the forearm. The radial head is the rounded end of the radius bone that meets the humerus at the elbow joint; its shape allows the forearm to rotate so the palm can face up or down.

Normally, the elbow joint allows the arm to bend and the forearm to rotate. In nursemaid’s elbow, the radial head partly slips out from under the annular ligament, a strong band of tissue that wraps around the radius to hold it in place. Part of the ligament can slide into the joint and get caught, causing pain and limiting movement.

Nursemaid’s elbow is usually caused by a sudden pull on a child’s extended arm while the palm is facing down. This force can make the annular ligament slip over the head of the radius bone. Common ways this injury happens include:

• Lifting a child by one arm, wrist, or hand, such as when helping them up a step or curb
• Swinging a child by the arms or hands during play
• Pulling on a child’s arm to prevent a fall or to guide them quickly
• Rolling over in bed in an unusual way, especially in infants younger than six months
• Twisting the forearm

Rarely, nursemaid’s elbow can occur after a fall onto an outstretched arm or from direct trauma to the elbow. These situations are more likely to cause a fracture than nursemaid’s elbow.

Risk factors for nursemaid’s elbow include:

• Age between six months and seven years
• Weak or loose annular ligament
• Sudden pulling on the arm, wrist, or hand
• Lifting a child by one arm, wrist, or hand
• Swinging a child by the arms or hands
• Rolling over in bed (especially in infants)
• Previous episode of nursemaid’s elbow (increases risk of recurrence)
• Female sex (slightly higher risk)
• Left arm (more commonly affected than right)

Symptoms of nursemaid’s elbow may include:

• Crying or distress at the time of injury
• Refusal to use the affected arm
• Pain in the elbow or forearm, especially when trying to move it
• Holding the arm in a slightly bent (flexed) position against the belly with palm facing down
• Inability or unwillingness to bend the elbow or rotate the forearm
• Mild tenderness over the elbow, especially at the radial head (the rounded end of the radius bone at the elbow)
• Moving the shoulder but not the elbow

Usually there is no swelling, bruising, or deformity of the elbow. Symptoms may improve after the initial pain, but the child continues to avoid using the arm because movement causes pain to return.

A child who is suddenly unable to move their elbow should be evaluated by a health care provider without delay to ensure proper diagnosis and treatment.

To diagnose nursemaid’s elbow, a doctor will review the child’s medical history and conduct a physical exam. In some cases, they may order one or more diagnostic tests.

The doctor may ask about how the injury happened, such as whether the child’s arm was pulled, lifted, or swung. They will also ask about the child’s symptoms, including pain, refusal to use the arm, and any previous episodes of nursemaid’s elbow.

During the physical exam, the doctor will look for signs such as the child holding the arm close to the body and refusing to move the elbow and check for tenderness over the radial head. They will also check for swelling, bruising, or deformity. These are not common in nursemaid’s elbow but may suggest a fracture or other injury. The doctor may also gently feel the entire arm, shoulder, and clavicle to rule out other injuries.

Additional tests may be necessary, including:

• X-ray of the elbow may be used to rule out fractures or dislocation if the injury did not occur in the typical way, if there is swelling, bruising, or deformity, or if the child does not regain arm movement or attain pain relief after treatment.
• Ultrasound imaging may be used in some cases to help diagnose nursemaid’s elbow, but is not usually needed.

After treatment, the doctor will observe whether the child begins to use the arm again. Sometimes, the doctor may encourage the child to reach for a toy or object to see if normal movement returns.

Nursemaid’s elbow can be treated in the doctor’s office. There is no need for surgery or long-term immobilization in most cases.

The main treatment is a closed reduction of the joint, in which the doctor gently moves the bones back into place. The doctor will use one of two methods.

• The hyperpronation method involves turning the forearm so the palm faces down beyond the normal range (hyperpronation) while applying pressure to the radial head.
• The supination/flexion method involves turning the forearm so the palm faces up while at the same time bending the elbow.

With either method, a click or pop may be felt or heard when the joint goes back into place. This procedure can be frightening but usually takes only a few seconds and does not require sedation or pain medicine.

After reduction, the doctor observes the child to see if normal arm movement returns. Most children regain full movement within 10 to 20 minutes.

If needed, pain relievers such as ibuprofen may be given, especially if the injury has been present for several hours or if there is swelling. Applying ice to the elbow may also help reduce discomfort and swelling.

If normal arm movement does not return after reduction and imaging shows no fracture, additional testing may be needed, or the child may be directed to follow up with a pediatric orthopaedic specialist.

Since nursemaid’s elbow can occur again, parents and caregivers can reduce the likelihood of future injuries by lifting children from under their arms, and not pulling, lifting, or swinging the child by their arms, wrists, or hands.

If a child has several recurrences, after ruling out more serious problems, the doctor may teach parents or other caregivers how to perform the reduction maneuver at home.

Children with nursemaid’s elbow may be at increased risk for certain complications, including:

• Recurrence: The injury may happen again, especially in the weeks after the first episode.
• Limited arm movement: Rarely, the child may continue to have difficulty moving the elbow.
• Swelling or bruising: Although uncommon in nursemaid’s elbow, these may occur if another injury is present.

If normal arm movement does not return after treatment, further tests and specialist care may be needed.

The outlook for nursemaid’s elbow is excellent in most cases. After the bone and ligament are returned to their normal positions, most children regain full use of the arm within minutes to hours. Children usually do not need any further treatment, immobilization, or follow-up after successful reduction. The injury does not commonly cause permanent damage.

Recurrence is possible, especially in the weeks following the first episode. Up to one-third of children may experience nursemaid’s elbow again, but the risk decreases as the child grows older, and the ligaments become stronger.

Parents and caregivers can help prevent future injuries by lifting children from under the arms and avoiding sudden pulling or swinging them by the hands or arms.

“Yale Medicine stands out for its child- and family-centered approach,” says Ariel Williams, MD, a Yale Medicine orthopaedic surgeon who specializes in hand and upper extremity surgery. “We treat the full spectrum of upper extremity injuries in children—from the most common conditions like nursemaid’s elbow to the most unusual and complex cases. Our pediatric specialists are committed to providing expert, evidence-based care in a convenient, family-centered way, so every child receives the right treatment at the right time, as comfortably as possible.”