Pulled elbow

subluxation of the annular ligament due to a sudden longitudinal traction applied to the hand.
Age: usually 1 to 4 years old
In 50%: no history of a “pull” on the arm

Examination:
- not using the affected limb
- elbow in extension and the forearm in pronation
- distressed only on elbow movement
- no swelling, deformity or bruising of the elbow or wrist
- on palpation tenderness is usually absent (remember the clavicle)
- marked resistance and pain with supination of the forearm.
- Manipulation during triage or xray may reduce the subluxation.

Differential diagnosis for upper limb non-use guideline
- Fracture
- Pulled elbow
- Joint pathology
- Infective process
- Neurological lesion

Diagnosis
- Clinically established with a classic history and examination.
- Plain radiographs are indicated when a differential diagnosis is suspected:
  - significant tenderness, swelling, bruising or deformity
  - reduction fails

Investigations

Often normal XR findings
25% will show radiocapitellar line slightly lateral to centre of cepitellum

NB: do not normally need XR if there is reliable history of traction of elbow, clinical examination suggestive of pulled elbow & child is < 5yrs age

XR if there is atypical history or examination

Treatment
- Perform a reduction manoeuvre
- expect distress and pain
- a click may be felt over the radial head
- review after ten minutes

Reduction manoeuvres

Either of the following methods may be effective

forearm supination (often done during XR manoeuvres) – snapping can be heard and palpated when annular ligament reduces. Full arch of supination to pronation of the forearm with elbow flexion & extension will reduce all pulled elbows.
Hyperpronation technique – hyperpronation of forearm while in the flexed position

Hyperpronation manoeuvre

Sit the child on the parent’s lap

Supination/flexion manoeuvre

Sit the child on the parent’s lap

If the reduction is successful, the child should be pain free and able to move the arm normally in 5 to 30 minutes, including being able to reach for an object above the head

In cases where reduction is felt to be successful, but the injury is greater than 12 hours old, the child may take 1-2 days to use the arm again

Pulled Elbow Patient INFO

Definition:

Common injury among children under five.
Caused by the partial dislocation of the radius bone at the elbow joint.

Causes:

Sudden pull on a child’s lower arm or wrist.
Lifting a child by one arm.
Falls.

Signs and Symptoms:

Immediate crying after the injury.
Inability to use the injured arm.
Arm hangs by the side.
Ligament overstretched, allowing the bone to slip out.

When to See a Doctor:

Seek immediate medical treatment from a GP or emergency department.
Delayed treatment increases pain and difficulty in reduction.

Treatment:

Reduction by a nurse or doctor to manipulate the bone back into place.
Procedure is momentarily painful but quick.
Observation post-reduction to ensure normal arm use.
X-ray not typically necessary unless reduction is unsuccessful or another injury is suspected.

Care at Home:

Child should return to normal activities post-treatment.
Pain medicine may be needed if the elbow was dislocated for a prolonged period.
If the child isn’t using their arm by the next day, return to the doctor for reevaluation.

Prevention:

Avoid lifting children by their lower arms or wrists.
Lift children using their armpits.
Educate caregivers on proper lifting techniques.
Less common in children over five due to stronger joints.

Key Points:

Sudden pull on a child’s arm can cause a pulled elbow.
Immediate medical attention is necessary for quick and effective treatment.
No long-term damage if treated promptly.
Correct lifting techniques can prevent recurrence.

For More Information:

Consult your GP.
Refer to Kids Health Info factsheet on pain relief for children.

Pulled elbow