The Hurty Elbow

aka Paediatric Perplexity 014

So it’s the first shift of a run of nights. A tearful mum has brought in 18-month old Bobby who is complaining of left wrist pain for around 12 hours.

She believes it started after he fell on a trampoline. Ibuprofen was given with some effect prior to bed, however the pain was worse through the night.

Observing Bobby: he was not using his left arm, and consistently pointing to his lateral left forearm which he described as ‘hurty’. There was no obvious deformation of the elbow or wrist, and inconsistent reaction to palpation and ranging of both joints.

You surmise that Bobby is suffering from a ‘pulled elbow’

Q1. What is a Pulled Elbow?

Answer and Interpretation

A pulled elbow is a subluxation or partial dislocation of the radial head.

This occurs in young children as the annular ligament surrounding the radial head slips easily over the developing radial head and slides into the radio-humeral joint.

Pulled elbow is also known as ‘Nursemaid’s elbow’, which heralds from a time where Nursemaid’s were commonplace as primary caregivers for children, and thus be the person to pull on a child’s arm who was perhaps uncooperative or to prevent an accident (e.g. running across the road)

Q2. What is the mechanism of injury?

Answer and Interpretation

Pulled elbow is the most common elbow injury in children usually <5 years of age.

Pulled elbow usually occurs as a result of a sudden pulling motion in axial traction with the elbow extended. For example: when an adult is walking with the child and the child is pulled briskly back from danger or when a child is pulled from sitting to standing .

However in up to 50% of cases there is no documented pull on the arm.

  • Unwilling to use that arm, often held by the side pronated with slight elbow flexion.
  • No wrist or elbow deformity or swelling (don’t forget to look at the clavicle) and usually no focal tenderness on palpation
  • Resistance and pain with any elbow or forearm movements

After discussing injury mechanisms with mum she remembered that she in fact pulled little Bobby off the trampoline by the left wrist with his arm extended!!

Q3. Should I request an X-ray?

Answer and Interpretation

Most cases can be diagnosed on clinical assessment alone and do not require imaging.

  • There are no specific x-ray changes associated with pulled elbows and the role of x-rays is limited to ruling out a fracture.
  • If there is no history of a sudden traction to the arm; the mechanism of injury unclear; there has been direct trauma to the elbow, or there is any swelling, bruising or deformity – an x-ray should be requested.
  • Imaging may also be required if the child fails to use the elbow normally after a period of observation post attempted reduction.

Interestingly, it is not uncommon for the radiographer, when positioning the arm for x-rays, to unwittingly reduce the pulled elbow.

Q4. How do I reduce a pulled elbow?

Answer and Interpretation

There are two manoeuvres that are described to reduce the radial head subluxation:

  • hyperpronation
  • the supination/flexion method.

Neither requires sedation, however you should warn the parents it will be briefly uncomfortable as it relocates.

A recent meta-analysis of the two techniques showed that hyperpronation is the preferred technique (greater success rate and may be associated with less pain)

Following relocation, the child commonly has almost immediate pain relief, evidenced by normal use of the arm within 30 mins.

Frustratingly, a proportion of children with typical features of a pulled elbow fail to respond to initial reduction attempts.

Options at this stage are to x-ray the elbow and, if normal, repeat the reduction manoeuvre (often by a different practitioner), or to place the child’s arm in a sling and arrange review in 24 hours.

Q5. What should my discharge advice be?

Answer and Interpretation

This injury reoccurs in approximately 30% of children, so advise parents about the typical mechanism of injury and to avoid any tugging to the child’s extended arm in the future.


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Paediatric Perplexity

Emergency Medicine Physician, #FOAMed advocate and self confessed rugby tragic | @JohnnyIliff | LinkedIn

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