see also:

• orthopaedics in the ED
• RCH patient information sheet - pulled elbow (pdf)

• 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.

• 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).

• 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.

• 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⁾

• 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.