annular ligament displacement, part deux

As a follow-up to my own entry on nursemaid’s elbow, my daughter, while playing with her friends, ended up getting nursemaid’s elbow again yesterday (12/27/2004). Determined to see if anyone has documented a treatment protocol, I found a wonderful article on looksmart findarticles from The American Academy of Pediatrics: – Recurrent nursemaid’s elbow treatment via telephone – annular ligament displacement – Experience and Reason–Briefly Recorded
Pediatrics, July, 2002, by Robert E. Kaplan, Kathleen A. Lillis

The first interesting thing to note is that they say that nursemaid’s elbow isn’t so much a subluxation (dislocation) as “a displacement of the annular ligament between the capitulum of the distal humerus and the radial head. (2) The radial head does not move out of its position relative to the capitulum.” Basically, nursemaid’s elbow is not actually “subluxation of the radial head” but instead “annular ligament displacement” (ALD).

After much interesting medical discussion, the article contains two case studies of where a non-medical caregiver was instructed by telephone to treat the ALD rather than going to an Emergency Department (ED) to be treated by hospital staff. The first case study contains the following dialogue:

The child’s uncle was then given the following instructions: “This is what I want you to do. First, grasp your nephew’s right hand with your right hand. Now, place your left hand under his elbow to support it. Then straighten out his arm so the palm is facing upward. Then in one quick and fluid movement, swiftly bend his elbow up, and touch the palm of his hand to his same shoulder.” The instructions were clarified with the uncle and the maneuver was then performed. After the maneuver, the uncle reported that he “heard a pop.” The pediatrician called back in 10 minutes. The child was reported as “back to normal,” and was reaching his right arm over his head.

Later on in the article, the essence of the technique is described:

Two maneuvers are commonly used when attempting to reduce ALD: supination or pronation (sometimes termed hyperpronation). (6,7) Supination is simultaneous supination of the forearm and extension of the elbow, followed by flexion of the elbow as described in the case reports (Fig 4). A very effective pronation maneuver is termed the “handshake” maneuver. (8) We have adapted the maneuver to include extension of the elbow, because we find it easier to perform. In this maneuver, one grasps the hand of the patient’s affected arm as if to shake it. The other hand is placed under the affected elbow. The patient’s forearm is then simultaneously pronated and the elbow is extended. The elbow is then flexed with the forearm maintained in pronation to complete the maneuver (Fig 5).

Supination is defined as “rotation of the forearm and hand so that the palm is up” and pronation is defined as “rotation of the forearm and hand so that the palm is down” according to the MedTerms™ medical dictionary. So, in layman’s terms, for “supination” you rotate the forearm (the part of the arm from elbow to hand) so that the palm is up, extend the elbow (straighten the arm), then flex the elbow (bend the arm). When bending the arm, bend it so the child’s palm ends up basically touching the shoulder of the arm that’s being bent. For “pronation”, particularly the “handshake” method that’s described above, you hold the child’s hand as though you were going to shake hands, then as you extend the forearm (straighten at at the elbow) you rotate the hand so that the child’s palm faces downward, then flex the elbow (bend the child’s arm) keeping the palm facing downward, bringing the arm across the child’s chest towards the other shoulder.

Now, a caveat: I’m no doctor, I just play one on the Internet, here — before you attempt any of this on your own child, I strongly advise you contact your pediatrician, but asking them to walk you through the procedure over the phone may save you a trip to their office, and definitely a trip to the Emergency Department of your local hospital. Our local hospital apparently sees three to four children a day with nursemaid’s elbow — and at $400 a pop, that’s some good money they’re making.

I hope none of you parents have to deal with the annular ligament displacement (ALD) aka “Nursemaid’s elbow”, but if you do, you may want to learn how to treat it yourself, especially if it’s recurrent (happens again and again)!


  1. I wish I had seen this article prior to an urgent care visit with our toddler last month. The visit has ended up costing us over $300. The ligament displaced again the other day and I successfully performed “surgery” on my son and fixed it myself, saving us an additional $300!

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