Pulled elbow

Aim

To guide Emergency Department (ED) staff with the assessment and management of children who present with a pulled elbow.

Key points^1,2

• A pulled elbow is where there is partial subluxation of the radial head, with the orbicular ligament slipping off the end of the radius.
• This is a common injury in toddlers 2-3 years of age (reported age range = 6 months - 7 years).

Assessment

• The history is central to the diagnosis
• The child is often undistressed, but reluctant to use the arm, and cries if the arm is moved
• The child usually holds the affected arm motionless, in a mid-prone position in front of the chest, kept still by the opposite hand.

History

• A sudden longitudinal pull or axial traction on the arm of an infant or toddler, while the arm is extended
• Typically, the injury may occur when a parents grabs a child by the arm as the child is running away or falling or being swung around by the arms.
• If the history is typical, and examination fits with the diagnosis, then X-ray is not necessary
• If the history or examination are not typical, then X-rays should be done to exclude other injuries before attempting to manipulate the arm.

Examination

• There may be mild focal tenderness over the radial head, but generally there is no specific bony tenderness
• Very gentle exclusive supination-pronation of an otherwise still forearm will cause distress (i.e. rotation of the radial head)

Investigations

• No X-rays are required unless the history is atypical.

Management^1,2

Reduction

• First explain to the parents that there will be a brief moment of pain followed by complete relief of pain. Sit the child on the parent's knee.
• Consider and offer oral analgesia 30-60 minutes prior to the reduction. Refer to Analgesia – ED Guideline

Method 1:

• With the elbow semi-flexed, grasp the forearm with one hand, and place the thumb of your other hand over the lateral aspect of the elbow.
• Pronate the forearm fully, and if not immediately successful, supinate fully.
• Reduction is almost always associated with a clicking sensation which may be both heard and felt.
• If reduction hasn’t occurred at this stage, flex the elbow fully while keeping the elbow supinated.

Method 2:

• Flex the elbow and supinate in one fluid motion
• If reduction is successful, then the child should start using their arm freely a short while (within 10 minutes) after reduction.
• No immobilisation is necessary after reduction.

If reduction has been unsuccessful, then an X-ray should be done to exclude a different injury.

• If the X-ray is normal, then reassure the parents that spontaneous reduction almost always occurs.
• A sling can be applied, appropriate analgesia given, and the child reviewed the following day.

References

1. Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom-Smit LWA, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD007759. DOI: 10.1002/14651858.CD007759.pub4
2. Aylor M, Anderson JM, Vanderford P, Halsey M, Lai S, Braner D. Reduction of Pulled Elbow. N Engl J Med 2014; 371:e32 November 20, 2014 DOI: 10.1056/NEJMvcm1211809

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