Pulled elbow

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

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Aim

To guide staff with the assessment and management of children who present with a pulled elbow.

Key points

  • 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).

Partial subluxation of the radial head, with the orbital ligament slipping off the end of the radius

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 (“whizzy dizzy”)
  • 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

Reduction

First explain to the parents that there will be a brief moment of pain followed by complete relief of pain.

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.
  • Supinate the forearm fully, and if not immediately successful, pronate fully.
  • Reduction is almost always associated with a clicking sensation which may be both heard and felt.

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.

  • Bibliography

  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

Endorsed by:  Director, Emergency Department  Date:  Feb 2018


 Review date:   Feb 2021


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