Pulled elbow, or radial head subluxation, is a common  in children aged 1-4 years. It occurs when the radial head slips out of the annular ligament due to a sudden pulling force on the extended and pronated arm. The condition is generally benign and easily treatable, with no long-term consequences.

pulled elbow pathophysiology

 

 

History and examination

  • Age 1-4 years
  • Risk factors: Sudden pulling or lifting of the child’s arm, history of previous pulled elbow
  • History: Sudden onset of pain and inability to use the affected arm after an incident of pulling or lifting
Symptoms Signs
  • Pain in the affected elbow
  • Reluctance to move the affected arm
  • Arm held in slight flexion and pronation
  • Tenderness over the radial head
  • No swelling or deformity
  • No sign of inflammation

 

Differential diagnosis (D/D) & Complication

D/D:

    1. Fractures (Trauma history, localized tenderness, deformity)
    2. Dislocation (Significant trauma, visible deformity, severe pain)
    3. Sprains (Trauma history, swelling)

 

Complications: Recurrent episodes of pulled elbow

 

Investigation

  • Usually not required for diagnosis
  • X-ray may be considered if a fracture is suspected
  • Ultrasonography has been done to show a widened radiocapitellar interval and a torn annular ligament. Ultrasound too is not done routinely when the diagnosis is clear.

Admission criteria

  • Not required

Management

  • Emergency management:
    • Perform reduction maneuver  to relocate the radial head
      •  Supination-flexion
      •  Hyperpronation techniques
    • Assess the child’s ability to use the affected arm after reduction
  • Medical:
    • Analgesics (e.g., paracetamol) for pain relief if needed

Note:  Usually the flexion supination maneuver causes a little more pain during reduction as opposed to the pronation method. Post reduction there is no need of immobilization as the child will actively use the upper limb.

 

Advices

  • Educate parents about proper handling techniques to prevent recurrence (e.g., avoid pulling or lifting the child by their arms)
  • Recurrence rates between 26.7 and 39%. Tell parents that once this has occurred then it can recur up to the age of 5 years. If it recurs then they should take the child to the emergency room where it will be reduced.
  • Tell the parents to pick up the child by lifting under the axilla instead.

Referral

  • Refer to an orthopedic specialist if reduction is unsuccessful or if the child has recurrent episodes

Follow up

  • Follow up is typically not necessary unless complications or recurrent episodes occur

References

  1. Quan, D. J., & Teach, S. J. (1999). Radial head subluxation: epidemiology and treatment of 87 episodes. Annals of Emergency Medicine, 33(5), 529-534.
  2. Krul, M., van der Wouden, J. C., Kruithof, E. J., van Suijlekom-Smit, L. W. A., & Koes, B. W. (2017). Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews, (7).
  3. Schutzman, S. A., Teach, S., & Fleisher, G. R. (1991). Nursemaid’s elbow: a preventable injury. Pediatrics, 88(2), 394-397