Nursemaid’s Elbow

Another in our recent orthopedic themed posts: a common toddler injury called “dislocated radial head.” I call it my favorite diagnosis, because  here a child walks into my office sick (elbow pain) and walks out cured (pain resolved).

A quick anatomy lesson illustrates what happens and how this disorder received its common nickname. As illustrated, the forearm consists of 2 bones–the ulna (pinky side) and the radius (thumb side). The elbow end of the radius is shaped like a knob which allows that bone to rotate over the ulna at the elbow, allowing you to turn your palm down or up (pronate or supinate); a U shaped sling like ligament holds that knob end against the ulna so the radius can rotate and turn the palm over.  In toddlers that ligament and the surrounding muscles are not as strong making the joint more injury prone.

That’s where the funny name from the title comes in: classically, the caregiver (nursemaid) gives a strong tug by the hand to the dawdling child to “keep up,” causing that knob end of the radius(at elbow) to get pulled under and past the U shaped ligament “dislocating” it.  Basically any vigorous pull at the hand from a considerably stronger individual can cause it: pulling the child up from or to avoid a fall, too vigorous play/pulling arm by an older sibling.

The child will often cry out in pain and then hold the injured arm flexed 90 degrees at the elbow against their trunk. Any attempt to move the arm is very painful and will be strongly resisted.  Noticeable swelling or discoloration at the joint is uncommon. The diagnosis is generally straightforward given the history of a pull at the child’s hand followed by pain and resistance against any movement thereafter.  It’s usually pretty easy to fix with a simple maneuver in the office.  (I encourage the “DIY”ers among you to leave that treatment to trained professionals–its your kid, not some kitchen appliance!) X rays aren’t required unless history isn’t clear, in which case, ruling out a fracture may be necessary. Curiously, it is not rare for the x ray tech to inadvertently reduce the injury while manipulating the arm to  get optimal views for the radiologist. That’s ok, too.

After the dislocation is reduced, I frequently find that the child will continue to resist moving the elbow out of fear of more pain: I hold the uninjured arm and offer a lollipop; after a while they can’t resist, take the candy with the cured arm and realize that now it’s ok again. Follow up care is ice for swelling and ibuprofen for pain.  Once the injury has occurred, the ligament is looser and more prone to re-injury.  It is best to avoid pulling any young child hard by the hand, ever.  In rare instances of multiple recurrences of this injury, orthopedic intervention to tighten the lax ligament can relieve that problem.

Please give me a call with questions and comments, and thanks for following. Featured image from:

Patellofemoral Syndrome

Having previously discussed Osgood Schlatter, let’s stick with this theme and turn to another very common knee problem, patellofemoral syndrome (PS).  PS is actually THE most common cause of knee pain from non-acute trauma in adolescents, in either athletes or those not engaged in organized physically competitive endeavors.

The hallmark of PS (sometimes called “chondromalacia of the patella which is actually only one form of PS) is pain in the knee just behind the kneecap (patella).  PS is also often called “runner’s” or “jumper’s” knee, because the problem is closely associated with, and exacerbated by, those activities/movements.  Kids with PS also commonly complain of worsening pain after sitting still for extended periods.  Some PS sufferers will note a popping or crackling sensation in the knee, especially upon climbing stairs.

No one knows the exact cause and in fact it likely has several contributing and compounding issues. The most common factor is wearing/thinning of the cartilage BEHIND the patella (NOT “meniscus”). The soft, smooth cartilage behind the kneecap and covering the lower end of the thighbone(“femur”) is a much more lubricated joint surface for movement than rough, hard bone. When/if that cartilage wears down it causes inflammation and pain.

The condition is usually brought on by some aspect of sub-optimal exercise/training routine: too much training, a sudden increase in training intensity, improper training technique,  using improper equipment(or proper equipment improperly) including footwear, bad or sudden change in training surface.

One common factor is quadriceps asymmetry.  The quadriceps is the main thigh muscle, responsible for straightening the leg at the knee by pulling the shin (“tibia”) forward at the knee joint.  As its name implies, the muscle has 4 parts, and if some sections are stronger/weaker than others the patella is not pulled straight through that cartilage lined groove at the bottom of the bone but rather will shimmy and bounce through it, causing the surface to wear down over time, leading to PS.

Thus a mainstay of treatment for PS is a good quadriceps strengthening program.  Also along those lines, I encourage athletes to avoid full “squats” generally and in particular if you have PS.  Half squats are usually ok. if they don’t cause pain.  If you must do full squats with weights, I encourage flexing the knee < 90 degrees and only use machines/apparatus where the weight is placed past the feet and pushed away from the body as opposed to the weight on the shoulders to be lifted.  A period of rest before return to sports is optimal or at least a modified training program limiting running/jumping outside of actual competition(substitute bike, low impact aerobic machines like elliptical trainer, swimming, water running). Heat before, ice after all vigorous activity. Wear a neoprene knee brace open at the patella for support during exercise. Anti-inflammatory medications like ibuprofen are often beneficial but not essential. 

Of course, if the pain is more disruptive or persistent then please come on in and let’s take a closer look together.  Thanks for following.