Pulled Elbow

What It Is

'Pulled elbow' (nursemaid's elbow) is a subluxation of the head of the radius from under the annular ligament, occurring almost exclusively in young children aged about 1–4 years. The mechanism is a sudden longitudinal pull (traction) on the pronated forearm — classically a carer lifting or swinging the child by the hand, or a sudden tug. At this age the radial head is small and not yet fully formed, so it slips out from the annular ligament, which then becomes partly interposed in the joint.

Clinical Features

The child suddenly refuses to use the arm and holds it slightly flexed and pronated, and cries if it is moved. There is usually no swelling, no deformity and no bruising, and often no clear history of a fall — which is the key point that distinguishes it from a fracture. Tenderness, if any, is over the radial head. Because the picture is so benign, radiographs are usually normal and are not routinely required when the history is typical.

WHY It Happens Only in Small Children

The injury is confined to this age group for an anatomical reason: in the toddler the radial head is still largely cartilaginous and almost the same width as the radial neck, so the annular ligament that encircles the neck can slip up over the head when the arm is pulled. As the child grows, the radial head enlarges and becomes bulbous, and the ligament can no longer ride over it — which is why pulled elbow essentially disappears after the age of about five.

Management

Treatment is a simple closed reduction manoeuvre: the elbow is held and the forearm is fully supinated and then flexed (alternatively, hyperpronation), during which a click is often felt over the radial head. The child starts using the arm again within minutes, and no immobilisation is needed. Parents should be reassured but advised to avoid pulling the child by the hand, as recurrence is common until the child is older.

Supination-flexion manoeuvre reduces it instantly.

• Pulled (nursemaid's) elbow = subluxation of the radial head from under the annular ligament, in a child 1–4 years old.
• Mechanism: a sudden longitudinal pull on the pronated forearm; the child refuses to use the arm and holds it flexed and pronated, with NO swelling or deformity.
• X-rays are usually normal and not needed with a typical history; obtain them if there is a fall, swelling or bony tenderness (to exclude a fracture).
• Reduce by supination + flexion (or hyperpronation) — a click is felt, the child uses the arm within minutes, and no immobilisation is required.