Nursemaid's elbow

One of the characteristics of a long medical career is the kaleidoscope of educational experiences one draws upon. This afternoon a three year old boy and his father benefitted from one of my early lessons, courtesy of Mary Mahotka, an x-ray tech in the Verona Family Practice Residency Clinic

I had been a second year resident and the patient was a toddler with arm pain after his older brother had yanked him off the bed. Because he wouldn’t use that arm, his mother had brought him straight to our clinic for evaluation. He had been more apprehensive than in pain, and sat there using his right arm to hold his left arm against his upper abdomen, slightly bent at the elbow. There was no visible or palpable deformity or bruising. As long as I did not move his elbow or try to rotate his forearm so the palm was facing up, he seemed fine. Concerned about a fracture of the radius, where he said it hurt, I sent him down for an x-ray. That’s when Mary called. 

“I can x-ray it if you want,” she said “but it would make more sense for me to show you how to fix it.”

I had only been at the clinic for a few months, but I had already learned that Mary was to be trusted, so I stopped charting and hurried down. She had an x-ray of an elbow up on the view screen and my patient and his mother were sitting on the x-ray table, looking for all the world like a first grade class waiting to greet the teacher. I almost expected to hear the familiar ritual: “Good morning, Ms. Mahotka.” “Good morning, class.”

Looking at the Mom and my patient (but speaking as much to me as to them) she pointed out the important aspects of the anatomy of a young elbow and explained that traction could easily pull the head (or top part) of the radius out from the annular ligament that holds it in place, causing a painful subluxation or incorrect positioning of the bone, but no fracture. She told them (and me) that an x-ray was rarely needed, and that nursemaid’s elbow was so easy to ‘reduce’ the ‘subluxation’ that it often happened spontaneously when the arm is placed down on the x-ray table to take a film.

“I’m not allowed to actually treat your elbow, but let me show you how it’s done,” she had said. She showed me how to hold his elbow in one hand and use my thumb to put pressure on the radial head, positioned my other hand on his wrist, and explained that if supinated his forearm (turned it palm up) and flexed the elbow (bent the elbow) with steady firm thumb pressure on the radial head I would feel the ‘pop’ as the bone slipped back into place.  I glanced at the mother, who clearly expected me to proceed, so I did. As I supinated and flexed he flinched and yelped once just as I felt the now familiar and reassuring pop. Mary reached into the pocket of her lab coat, pulled out a lollipop, and held it out for him. Without hesitation he reached out and took it with his previously injured arm.

So today, when the Dad came to our front desk, accompanied by his tearful three year old, and said he had pulled his son up into the pick-up when he started to cry and now wouldn’t move his arm, and could we arrange an x-ray, it just seemed natural to offer to take a quick look before we decided what to x-ray. The exam and the reduction combined took less than two minutes. When the much relieved Dad thanked me, I was tempted to say: “Don’t thank me, thank Mary.” Instead, I just nodded and smiled.

But thanks are due. So, thank you Mary. Thank you, and thanks as well to the many others who have helped me along the way.


 

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