pulled elbow is a very common cause of a child (usually under age 6 years) refusing to move their arm.
it is a subluxation of the immature radial head and is not detectable radiologically and thus is a clinical diagnosis.
it is usually caused by a parent, sibling or friend pulling on the child's arm - eg. stopping them from crossing a road, but may also occur from a hyperpronation injury which may occur as the child rolls over on top of their pronated arm.
if it has happened once, there is increased risk of recurrence until child is older than 6-7 years, thus parents should be informed to avoid pulling the child's arm.
clinical features
child under age 6-7 years
classically presents with affected arm held with elbow partly flexed and not wanting to move the elbow
in a coooperative child, it will be noted that gentle flexion and extension of the elbow is tolerated but any supination will cause discomfort
an important finding is the absence of a palpable elbow effusion posterior to the elbow (the presence of an effusion strongly suggests a fracture, or in the case of a child with haemophilia, just a haemarthrosis).
ED Mx of suspected pulled elbow
clinical diagnosis
Xray is NOT required if there is a good history and examination consistent with a pulled elbow
an Xray should be considered if the mechanism was a fall rather than a pull, or if there is a palpable elbow effusion.
reduction of presumed pulled elbow
if fall unlikely, and findings suggest pulled elbow, attempt reduction
traditional method of reduction is full supination with a flexed elbow
HOWEVER, it seems hyperpronation is more successful and less painful 1)
reduction failure
those who have atypical presentations and in whom attempted reduction fails, may be considered for Xray.
delayed presentations of more than a few hours may not be able to be reduced that day
these children can generally be allowed home with expectant spontaneous reduction within a few days once inflammation subsides.