One of the nicest milestones in a baby’s life, and in a parents’ life, is when a child starts to walk. This is of course accomplished in small increments that lead to walking. At first a child sits unsupported; this is followed by crawling, then standing. Most of the time, this act is repeated many times. The child will eventually stand and cruise around by taking steps holding on to steady objects until it eventually lets go and walks on its own.
Because the pelvic girdle is not yet developed, children will walk and put their weight on one leg, then the other. This is why they are called toddlers, because they toddle! And since they are now attempting to walk independently, all sorts of problems follow. Since walking is not so steady, they often fall. Objects that could not be easily reached before now are there within reach—tables, corners to bump into, etc. Walking outside is also a challenge. There are sidewalks to fall on, streets to run into! We, as adults, want to help our children who are constantly trying to become more independent. So what do we do? We hold their hands!
I suppose it would be better to hold them by their shoulders, but toddlers are generally much shorter than their parents and it would be a real strain to walk hunched over all the time. So we hold their hands. Frequently, toddlers wanting to wander free, or tired of standing, or whining because they are kids (my precious five never did that!), will plop down on the ground. Since they are still being held by the hand this puts strain on the child’s elbow, causing a very painful condition known as nursemaid’s elbow. This is actually a subluxation of the radial head, which is one of the bones that make up our forearm and elbow. When this occurs, a child will suddenly stop moving his arm. Most people think they have done something to the shoulder, though it is difficult to tell exactly where the pain is coming from because the child is in pain and will scream if anyone goes near.
The longer it takes to examine a child, the harder it is to reduce the subluxation. The reduction should never be attempted at home because damage can be caused if someone pulls on an elbow that is injured. Nursemaid’s elbow needs to be reduced (to put the dislocated elbow back in place), so a visit to an urgent care center or an emergency room is necessary. If a detailed history is obtained and there is no history of falling and hitting the elbow, an X-ray is not required. The child must be calmed down and examined gently. A skilled pediatrician can touch the whole arm and detect that the pain is not coming from the shoulder or the wrist. Once this is established, the next step is reduction.
Reduction of nursemaid’s elbow is not difficult, but the parent needs to understand what will happen. The child needs to sit comfortably in the parent’s lap while the doctor does a maneuver that involves rotating and flexing the forearm. This is painful, but if successfully done all pain subsides and the child starts to move the arm again. Sedation and pain medication are not necessary. The reduction is quick, lasting only seconds and unfortunately painful enough that the usual pain medications will not work. At times, more than one attempt needs to be made before the radial head returns to its usual, non-painful position. At times, even after successful reduction, the child will not move the arm. This is because there is usually some inflammation which takes a few hours to a day to resolve. The use of Tylenol or Motrin at this point is indicated. The child should be followed up to assure that the arm is moving correctly.
I always talk about prevention, and this is no exception. I was always taught by my grandmother to not hold a child by the hand but by the shoulder to avoid pulling on the arm. While most of the advice my grandmother gave me was extremely useful, this one is not practical. It is difficult to walk with a toddler and stay bent over. It is also difficult to not hold on a hand forcefully when the toddler goes to run into a street! The best we can do is to be careful and seek medical attention if this does happen!
If you have any questions you want answered, please address them to Dr. Giuseppina Benincasa-Feingold at “askthedoctor@jewishlinkbc.com.”
By Dr. Giuseppina Benincasa-Feingold
