Questions with Answers for Pulled Elbow in Children

Question-1 : What is pulled elbow?

Answer:  It’s most common upper limb injury typically found in pre-school children. Children between 1 to 4 years of age are most susceptible to this injury. This elbow injury occurs when the child’s hand is pulled with elbow straight.

Question-2 : How does the doctor diagnose pulled elbow?

Answer: Because the injured elbow is painful, the child presents with refusal to use affected upper extremity not allowing anyone to touch it or fold it and holds it by the side. The doctor can diagnose it based on the knowledge about manner of occurrence of injury and the way child holds the arm.

Question-3 : What exactly happens in pulled elbow?

Answer: The elbow joint is made up of 3 bones, the upper arm bone (humerus) and two forearm bones. The bone on the side of thumb/ outer aspect is called the radius and the one on the side of little finger is called the ulna. The radius rotates around the ulna during forearm movements of taking or screwing and giving or unscrewing. (supination and pronation respectively.)

When the child’s hand is pulled with the elbow in straight position and forearm in giving position (extended and pronated), the upper rounded part of the radius ( head) comes out of the joint and the structure holding it in place  (annular ligament) gets trapped in the joint causing pain and difficulty in movements (radial head subluxation) as this ligament as well as the shape of head of radius is immature in a child.

Question-4 : What causes pulled elbow?

Answer: This injury commonly occurs when the caregiver holds the child’s hand/wrist with elbow in straight and suddenly pulls it for example while swinging the child by holding the hand. Sometimes this injury can occur when the child falls with forearm trapped under the body. However, it rarely happens when the child falls directly on the elbow or on the outstretched hand and a broken bone is more likely in this situation.

Question-5 : Is an X-ray required to diagnose?

Answer: It is a clinical diagnosis. Radiographs are typically normal and can be avoided if there is no suspicion of associated bony injury. However, they should be considered if the history of trauma is not typical/ unusual.

Question- 6 : How is the pulled elbow treated?

Answer: Treatment consists of use of one of the two methods described below for repositioning the radial head into the joint and oral analgesics for pain relief.

• Supination flexion maneuver-

In this maneuver the clinician supinates the forearm by grasping the hand and at the end of supination flexes the elbow beyond 900. A click can be felt at the time of reduction when the radial head reduces back.

• Hyperpronation maneuver-

In this maneuver, the clinician grasps the hand of the affected extremity and hyperpronates the forearm keeping elbow in flexed position. This maneuver has a higher success rate of reduction even in late presenters and in cases where supination flexion maneuver has failed to reduce.

Question- 7 : Does the child’s arm need to be protected after this?

Answer: Any kind of immobilization after reduction is typically not recommended and the child usually starts using the extremity in 10-15 minutes time.
In case of a child who presents late after the incident, even though the radial head relocates with the maneuver, the pain and immobility may persist. In such children immobilization for 5 to 7 days with either a plaster slab or arm pouch with elbow flexion and forearm supination is helpful in reducing soft tissue swelling and pain.

Question- 8 : Can this happen again?

Answer: Similar or recurrent episodes of pulled elbow may occur but they are without any consequences.

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