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Elbow Woes

By Scott Hamilton, M.D.
March 9, 2020

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 and it’s 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 I was earlier, or having the hand jerked to hurry a slow toddler along. Sometimes, it even happens when a parent is trying to get a shirt off by 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 now they’ve stopped using that elbow and, instead, let it hang by their side while doing everything with the other arm. When parents bring them in, no x-ray is 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, you get a brief yelp from the child and, in a few minutes, they’ll give you a high five. Fixed!

To avoid this injury, of course, no tugging on hands or wrists. Pick up infants and toddlers under their arm pits. But kids like being swung around, and they can also dislocate when wrestling or falling just right. When they pop that elbow, bring ‘em in. And, ending on a bit of good news, kids prone to Nursemaid’s Elbow develop stronger annular ligaments and typically stop dislocating by age five.

Fast forward from two-year-old Tasia last week to 1994. I’m on the playground at Boudreaux Elementary in Gretna, climbing the ladder next to the monkey bars. Grab one bar, swing to the next and…I’m falling
through the air and land right on my arm. I’m crying. My elbow hurts so much. I went to my teacher, and she 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.

But, sometimes kids end this scenario with a swollen elbow that just won’t stop hurting. As we discussed last week, kids are vulnerable to dislocations, but they’re also 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 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 worse than last week’s Nursemaid’s Elbow. The elbow is swollen and sometimes blue from internal bruising, and it really hurts. These need to be x-rayed, treated and pain medicine needs to be prescribed. Sometimes all that’s needed is a cast to hold the broken elbow still and protect it while it heals, which usually takes four to six 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 be just sprained like mine was and get better in a matter of hours. But if it’s swollen and really painful? Come on in!