Toddlers' elbow dislocations likely to recur

Extending her arms in the air, the child allowed her father to slip on her flannel pajamas. When dad then held her right hand to adjust the sleeve, the toddler decided she'd had enough parental assistance and pulled her arm back from his gentle grasp.

The little girl started wailing and holding her arm limply against her side, leaving dad wondering what he had done. She had been perfectly fine and active just a moment before, but was now unable to lift or use her right arm.

Since there had been no significant trauma, it was highly unlikely that the arm had been fractured. The sudden onset of symptoms following a pulling motion of the arm made the girl's injury very likely to be a simple case of subluxation of the radial head, or to use a more up-to-date orthopedic term, a case of annular ligament displacement (ALD).

While it often seems as if a major injury to the shoulder or wrist must have occurred in these cases, the real problem lies between these two joints, in the elbow. This condition is actually the result of a temporary and fixable dislocation of the elbow joint and is more commonly known as nursemaid's elbow because an adult caregiver or parent is often on the other end of an arm that is inadvertently pulled during daily child care activities.

In a 2002 article in the journal Pediatrics, Drs. Robert Kaplan and Kathleen Lillis explain that a nursemaid's elbow occurs when a pulling motion on the arm causes a tear in the annular ligament, which normally wraps around the elbow end of the radius (one of the bones of the forearm). The radius then slides and briefly moves out of place, allowing a portion of the loosened annular ligament to slip over the radius and into the elbow joint.

The authors find that ALD is most common among 1- to 4-year-olds, noting that after age 5, the annular ligament strengthens and is less likely to tear and become displaced. About 25 percent of nursemaid's elbows will recur, most likely due to an underlying laxity or looseness of this ligament.

A quick repositioning maneuver - called a reduction - can return the joint to its usual healthy state, but it takes experience and a certain comfort level to firmly manipulate a crying toddler's arm. I direct parents to seek medical attention if this is their first episode of nursemaid's elbow. Some parents of "repeat dislocators" do become so adept at the reduction maneuver that they eventually choose to skip the ER or office visit and fix the problem themselves at home.

Kaplan and Lillis report that reduction of a nursemaid's elbow usually works, but caution that success is less likely if the elbow injury is more than 12 hours old. The physicians also advise referral to an orthopedic specialist if the little patient is still complaining of pain and not using the affected arm within one hour of the initial reduction maneuver.

• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.