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Pulled elbow

A pulled elbow, also known as nursemaid's elbow or radial head subluxation, is a common partial dislocation of the radial bone in the elbow joint that primarily affects young children, occurring when a sudden pulling force on the extended arm causes the annular ligament to slip over the radial head, trapping it between the radius and capitellum.^[1] This injury is most prevalent in children aged 1 to 4 years, with females slightly more affected than males and the left arm more commonly involved, accounting for over 20% of pediatric upper extremity injuries presenting to emergency departments.^[2]^[3] The condition typically arises from everyday activities involving axial traction on a pronated forearm and extended elbow, such as an adult swinging a child by the arms, pulling the hand to lift them, or yanking the arm to prevent a fall; it is rarely caused by direct trauma like falls.^[1]^[3] Symptoms appear immediately after the incident and include acute pain localized to the elbow, refusal to move or use the affected arm (often held in extension and pronation close to the body), and reluctance to supinate the forearm, though there is usually no visible swelling, bruising, or deformity.^[2]^[1] Diagnosis is primarily clinical, based on the child's history of a pulling event and characteristic arm positioning during physical examination to assess range of motion, with radiographs ordered only if a fracture or complete dislocation is suspected to rule out other injuries.^[3]^[1] Treatment involves a prompt closed reduction maneuver performed by a healthcare provider, such as hyperpronation of the forearm or supination-flexion of the elbow, which repositions the radial head and relieves symptoms within minutes in over 90% of cases, typically without need for sedation, splinting, or follow-up imaging if successful.^[2]^[1] Prevention focuses on avoiding pulling or swinging children by the hands or wrists, instead lifting them under the arms or using verbal guidance during play.^[3] Recurrence occurs in approximately 20% of cases due to the ligament's laxity in young children, but the injury resolves without long-term complications and becomes less common after age 5 as ligaments strengthen.^[2]^[1]

Introduction

Definition and Overview

Pulled elbow, also known as nursemaid's elbow or radial head subluxation, is a partial dislocation of the elbow joint in which the radial head slips beneath the annular ligament, trapping the ligament between the radial head and the capitellum of the humerus.^[1] This subluxation occurs when the annular ligament, a band of tissue that encircles and stabilizes the radial head, becomes displaced due to traction forces applied to the extended arm.^[2] The condition predominantly affects young children under 5 years of age, with peak incidence between 1 and 3 years, and is a common reason for visits to pediatric emergency departments. It accounts for over 20% of pediatric upper extremity injuries presenting to emergency departments.^[3]^[2] It typically arises from everyday activities involving pulling or lifting the child by the arm, such as swinging them by the hands.^[1] Pulled elbow was first described as a distinct clinical entity in the medical literature in the late 19th century, with Jonathan Hutchinson reporting cases of partial radial head dislocation peculiar to children in 1886.^[4]

Epidemiology

Pulled elbow, also known as radial head subluxation or nursemaid's elbow, is a common upper extremity injury in young children, with an estimated incidence of 2.7 emergency department visits per 1,000 children aged 0 to 18 years in the United States.^[5] In Europe, rates are similar, ranging from 1.2% annually among children aged 0 to 5 years in Scotland to 2.4 per 1,000 person-years in Dutch primary care settings for the same age group.^[5] These figures highlight its prevalence in pediatric emergency care, particularly in urban and suburban hospitals where data collection is robust. The condition predominantly affects toddlers, with a peak incidence between 1 and 3 years of age; studies report a mean age at presentation of 28.6 months, and approximately 44% of cases occurring in children aged 18 to 29 months.^[6] Demographically, it is more common in girls, with a female-to-male ratio of about 1.5:1 (59.7% female in large cohorts).^[6] The left arm is affected in 60% to 70% of cases, potentially due to habitual pulling patterns during child handling.^[6] Higher rates in this age group are linked to developmental ligamentous laxity, though the injury is rare beyond age 7. Geographic data primarily derive from urban emergency departments in North America and Europe, showing consistent patterns without marked regional differences.^[5] Incidence trends appear stable based on hospital records from 2005 to 2012, with no evidence of substantial increases or decreases within that period.^[6]

Clinical Features

Signs and Symptoms

Pulled elbow, also known as nursemaid's elbow or radial head subluxation, typically presents with a sudden onset of acute pain in the affected arm following longitudinal traction on the forearm.^[1] The child often refuses to use or move the injured arm, holding it protectively close to the body in a characteristic position of extension at the elbow and pronation of the forearm (palm facing downward).^[1]^[7] Physical examination reveals minimal or no visible swelling, bruising, or erythema around the elbow joint, distinguishing it from more severe injuries.^[1] There is usually localized tenderness over the radial head, and the child experiences significant discomfort when passive supination of the forearm or flexion of the elbow is attempted, leading to resistance against these movements.^[1]^[7] Children with pulled elbow commonly exhibit behavioral cues such as irritability and anxiety, particularly when the arm is touched or manipulated, but they may appear calm and free of distress while at rest.^[8]^[7] They often guard the affected limb by supporting it with the opposite hand, avoiding any active use.^[1] These symptoms typically persist for hours to days if the injury remains untreated, resolving promptly following successful reduction.^[1]^[7]

Risk Factors

Pulled elbow, also known as radial head subluxation or nursemaid's elbow, predominantly affects young children due to age-related anatomical vulnerabilities. It is most common in children aged 1 to 4 years, with peak incidence between 1 and 3 years, attributed to the relative laxity of the annular ligament surrounding the radial head.^[1]^[9]^[10] This condition becomes rare after age 6, as the ligaments thicken and strengthen with skeletal maturation, reducing susceptibility.^[11] Certain activities significantly elevate the risk by applying sudden longitudinal traction to the extended arm. Common scenarios include adults lifting a child by the hands or wrists, swinging the child by the arms during play, or abruptly pulling the child from a high chair or stroller.^[12]^[13]^[14] Even minor actions, such as tugging the arm to prevent a fall, can precipitate the injury in susceptible children.^[1] Demographic factors also influence incidence rates. Studies indicate a slight predominance in females.^[15]^[16] Additionally, a family history of joint hypermobility is associated with increased risk, with hypermobility observed in at least one parent in 48% of affected children compared to 10% in controls, suggesting a genetic predisposition to ligamentous laxity.^[17] Underlying medical conditions, though rare, can heighten susceptibility and recurrence risk. Children with connective tissue disorders such as Ehlers-Danlos syndrome exhibit greater joint hypermobility, leading to repeated episodes of radial head subluxation due to inherent ligament weakness.^[18] General joint hypermobility, even without a diagnosed syndrome, shows varying prevalence across studies and may contribute to risk.^[19]^[20]

Pathophysiology

Anatomy Involved

The proximal radioulnar joint, a key component of the elbow complex, involves the articulation between the radial head and the ulna, stabilized by surrounding soft tissues that enable forearm rotation. The radial head, the proximal end of the radius bone, forms a pivot-like structure that interacts with the capitellum—a rounded prominence on the distal humerus—and the radial notch of the ulna. This configuration allows smooth movement during pronation and supination of the forearm.^[21]^[3] Central to this joint's stability is the annular ligament, a circumferential band of fibrous tissue that encircles the radial head and attaches to the ulna's radial notch, effectively securing the radial head against the capitellum while permitting rotational motion. In its normal anatomical positioning, the annular ligament maintains close apposition of the radial head to the capitellum and ulna, preventing lateral displacement during everyday activities. This ligament's role in biomechanics is crucial for forearm rotation, as it acts as a retinaculum that guides the radial head's circular path without restricting supination (palm up) or pronation (palm down).^[21]^[22]^[3] In children, particularly those aged 1 to 4 years, the annular ligament exhibits developmental characteristics that influence joint vulnerability: it is thinner, more elastic, and loosely attached compared to adults, reflecting the overall ligamentous laxity during early childhood. This elasticity predisposes the ligament to potential slippage over the radial head under certain stresses, though in normal function, it continues to facilitate unimpeded rotation. By age 5 or older, the ligament strengthens and its distal attachments mature, reducing such susceptibility. Typical diagrams of the proximal radioulnar joint illustrate this setup in lateral view, showing the annular ligament wrapping the radial head snugly against the capitellum and ulna.^[21]^[22]^[3]

Mechanism of Injury

A pulled elbow, also known as radial head subluxation or nursemaid's elbow, typically results from a sudden longitudinal traction applied to the arm of a young child, particularly when the forearm is in a pronated position and the elbow is extended.^[1] This traction often occurs in everyday scenarios, such as a caregiver lifting the child by one arm, swinging them by the hands, or pulling the arm to prevent a fall.^[1] The biomechanical force generated during these events acts axially along the radius, exploiting the relative laxity in the child's elbow joint structures.^[23] The sequence of injury begins with the traction force pulling the radius distally relative to the ulna and humerus, which causes the annular ligament—normally encircling the radial head—to slip proximally over the radial head.^[1] This displacement traps the ligament between the radial head and the capitellum of the humerus, effectively interposing it in the radiohumeral joint and resulting in a partial subluxation of the radial head.^[23] The supinator muscle may also contribute to this slippage, as the combined pull elevates these structures proximally during the traction.^[24] This injury predominantly affects children aged 1 to 4 years due to the immaturity of their annular ligament, which is thinner and more elastic compared to adults, facilitating easier displacement.^[1] Pathophysiologically, the subluxation disrupts normal forearm rotation, particularly supination, by mechanically blocking the radial head's repositioning, though spontaneous reduction is rare without intervention.^[24]

Diagnosis

Clinical Diagnosis

The clinical diagnosis of pulled elbow, also known as nursemaid's elbow or radial head subluxation, relies primarily on a detailed history and targeted physical examination in young children, typically aged 1 to 4 years.^[1]^[25] A classic history involves a recent traction event, such as an adult pulling the child's arm upward by the wrist or swinging the child by the arms, often followed by sudden non-use of the affected arm; importantly, there is usually no history of significant prior trauma like a fall from height.^[1]^[26] In up to 50% of cases, caregivers may not recall a specific pulling incident, yet the abrupt onset of arm disuse remains a key clue.^[25] On physical examination, pseudoparalysis is evident as the child refuses to use or move the affected arm, often holding it in slight flexion or extension with the forearm pronated and supported by the opposite hand.^[1]^[3] There is typically no visible swelling, bruising, crepitus, or deformity, with minimal tenderness localized to the radial head; pain is provoked specifically on attempts at supination, while passive extension and flexion may be tolerated.^[25]^[21] Neurovascular status must be assessed and is usually intact, with normal distal circulation, sensation, and motor function.^[1] These findings align with typical symptoms of localized elbow pain and arm avoidance, though the diagnostic process integrates them into a cohesive clinical picture.^[2] Key clinical features include a history of traction, the arm held in pronation with elbow extension, and limited supination due to pain, which demonstrate high specificity for pulled elbow in toddlers when other trauma is absent.^[26]^[21] This clinical approach avoids unnecessary imaging in straightforward cases, as the presentation is highly suggestive in this age group.^[25] Bedside tests include gentle supination provocation, where rotating the forearm to a palm-up position elicits localized pain and resistance without attempting full reduction, helping to confirm the suspected subluxation prior to any therapeutic maneuvers.^[1]^[25]

Imaging and Differential Diagnosis

Imaging is not routinely required for the diagnosis of pulled elbow, also known as radial head subluxation, as it is primarily a clinical diagnosis based on characteristic history and examination findings.^[1]^[27] Plain radiographs, such as anteroposterior and lateral views of the elbow, are reserved for cases with atypical history, significant swelling, deformity, bruising, or tenderness that raises suspicion for an alternative injury.^[25]^[21] When performed, X-rays are typically normal but may reveal subtle displacement of the radial head relative to the capitellum, such as the radiocapitellar line passing slightly lateral to the capitellar ossification center in up to 25% of cases.^[21]^[1] Advanced imaging modalities like ultrasound or MRI are rarely utilized and offer limited utility in most instances. Ultrasound can confirm the diagnosis in equivocal cases by demonstrating displacement of the annular ligament or an increased echolucent area between the radial head and capitellum, with reported sensitivity of approximately 65% and specificity of 100%; however, post-2020 studies emphasize its role primarily in recurrent or diagnostic uncertainty scenarios rather than routine practice.^[21]^[28] MRI is even less common, typically reserved for complex or recurrent presentations to evaluate soft tissue structures or occult fractures, but it is not recommended for initial assessment due to its invasiveness and lack of necessity.^[27] Specific indications for imaging include failure of reduction attempts, bilateral involvement, neurological deficits, or any features suggesting nonaccidental trauma or alternative pathology.^[25]^[1] The differential diagnosis for pulled elbow encompasses several conditions that may present with elbow pain and limited arm use in young children, necessitating exclusion through history, examination, and selective imaging. Supracondylar fractures often feature significant swelling, ecchymosis, and limited range of motion in all planes, unlike the pronated extension posture typical of pulled elbow; radiographs confirm bony disruption.^[21]^[27] Septic arthritis presents with fever, erythema, and systemic symptoms alongside joint effusion on ultrasound or X-ray, distinguishing it from the isolated mechanical symptoms of subluxation.^[21]^[1] Brachial plexus injuries typically involve sensory or motor deficits beyond the elbow, such as weakness in the hand or shoulder, without the specific traction mechanism, and may require electromyography for confirmation rather than routine elbow imaging.^[27] Other considerations include radial neck or lateral condyle fractures, which show focal bony abnormalities on X-ray and more pronounced pain on palpation. Pulled elbow remains a diagnosis of exclusion, with imaging pivotal in ruling out these mimics when clinical features overlap.^[21]

Management

Reduction Techniques

The primary reduction technique for pulled elbow, or radial head subluxation, is hyperpronation of the forearm, which involves applying gentle pressure over the radial head while pronating the wrist to reposition the annular ligament.^[25] This method typically begins by seating the child on a parent's lap for comfort, supporting the elbow with one hand and placing the thumb directly over the radial head for palpation, then grasping the child's hand in a neutral position and fully pronating the forearm (palm facing downward) with steady downward pressure on the radial head until a palpable "click" indicates successful reduction.^[25] Hyperpronation achieves a first-attempt success rate of approximately 90%, as demonstrated in a 2024 randomized controlled trial involving 119 children under 6 years old.^[29] An alternative technique is supination-flexion, which entails supinating the forearm (palm upward) followed by sharply flexing the elbow to beyond 90 degrees while maintaining thumb pressure on the radial head.^[25] The steps mirror the initial positioning for hyperpronation but involve rotating the forearm into supination before flexing the elbow forcefully, again aiming for a palpable click.^[25] This approach has a lower first-attempt success rate of about 76% and is less favored due to increased procedural pain reported by patients.^[29] Sedation is rarely required for these maneuvers, as they are quick and well-tolerated in most children aged 1-4 years, though topical analgesia may be used if the child is distressed or the injury is over 12 hours old.^[25] Successful reduction is confirmed by a post-procedure test involving gentle pronation and supination of the forearm; the child should regain normal arm use within 5-30 minutes, becoming pain-free and actively moving the elbow without reluctance.^[25] Recent evidence from post-2020 randomized controlled trials supports hyperpronation as the superior initial technique, with significantly lower first-attempt failure rates compared to supination-flexion (9.8% versus 24.2%; risk ratio 0.41, 95% CI 0.19-0.98).^[29] A 2024 meta-analysis further indicates that hyperpronation yields higher success on repeat attempts following initial failure (odds ratio 3.79, 95% CI 1.57-9.16), reinforcing its preference to minimize multiple interventions.^[30]

Post-Reduction Care

Following successful reduction of a pulled elbow, the child should be observed for 15 to 30 minutes to assess for spontaneous arm use and resolution of pain.^[31]^[32] Most children resume normal arm movement within 5 to 15 minutes, often reaching for objects or toys as an indicator of success.^[33]^[32] If pain persists, over-the-counter analgesics such as acetaminophen or ibuprofen may be administered as directed by a healthcare provider.^[33]^[34] Immobilization with a sling is rarely required and is typically unnecessary after the first episode, as it does not improve outcomes and may discourage arm use.^[31]^[21] For follow-up, a routine clinical review is recommended within 24 to 48 hours if this is the initial occurrence and the child is not fully using the arm, to confirm recovery and rule out other injuries.^[32] If arm use does not return within 30 minutes post-reduction, a second attempt at reduction or elbow radiography may be considered before discharge.^[31] Parents should be advised to monitor for signs of recurrence, such as sudden refusal to use the arm, pain, or swelling, and to seek immediate medical attention if these occur.^[35]^[34] Temporarily avoid activities involving traction on the arm, such as pulling or swinging the child by the hands or wrists, to minimize risk during recovery.^[31]^[32] In cases of recurrent subluxations, particularly more than two episodes, referral to pediatric orthopedics is indicated for further evaluation, which may include imaging such as ultrasonography or radiography to assess annular ligament integrity.^[23]^[21] For recurrent events, short-term immobilization with a cast in flexion and neutral position for 2 days has been shown to reduce further recurrence rates compared to no immobilization.^[23]

Prognosis and Prevention

Outcomes and Complications

Pulled elbow generally has an excellent prognosis following successful reduction, with approximately 90% of children becoming asymptomatic and regaining full arm function within 30 minutes.^[1] Recovery typically occurs in minutes to hours, allowing immediate return to normal activities without the need for splinting or immobilization.^[2]^[21] Recurrence rates vary across studies, estimated at 5% to 30% overall, with rates up to 39% in children under 2 years during the first year post-injury.^[1]^[23] Some studies suggest joint hypermobility increases the risk of recurrence, observed in up to 73% of affected children compared to 50% in age-matched controls, though other research has not found a significant association.^[36]^[37] Complications are rare when promptly treated.^[2] In untreated or recurrent cases, chronic elbow instability may develop due to ligament stretching, potentially leading to persistent limited motion.^[1]^[2] Long-term outcomes are favorable, with no evidence of growth disturbances or permanent joint damage following appropriate intervention.^[21] Studies continue to report excellent results, emphasizing the importance of timely reduction to prevent any residual effects.^[21] Key factors influencing outcomes include younger age at the first episode, which heightens recurrence risk, the total number of prior episodes, and underlying joint hypermobility.^[36]^[17]

Prevention Strategies

Preventing pulled elbow, also known as nursemaid's elbow, primarily involves educating caregivers on safe handling practices to avoid axial traction on a young child's arm. Parents and guardians should refrain from pulling, tugging, jerking, lifting, or swinging children by the arms, wrists, or hands, as these actions can displace the annular ligament around the radial head. Instead, children should be lifted by supporting the trunk or under the armpits to distribute weight evenly and reduce strain on the elbow joint. Verbal cues or gentle guidance are preferable to physical pulling when directing a child's movement, promoting patience especially with toddlers who may resist or stumble.^[33]^[38]^[1] Ensuring a safe play environment further minimizes risks associated with common scenarios like sudden arm extension during falls or play. Caregivers should supervise young children closely during activities involving climbing, running, or interaction with furniture to prevent accidental traction injuries, such as a child slipping from a high chair or stroller while holding on by one arm. Securing child safety equipment, including high chairs and car seats with proper harnesses, helps avoid situations where a child's arm might be yanked during a fall or sudden stop. These measures address vulnerabilities in active toddlers aged 1 to 4 years, who are most prone to such injuries.^[2]^[39] Joint hypermobility has been associated with increased susceptibility in some studies, though evidence is mixed. In recurrent cases, physical therapy focusing on strengthening forearm and shoulder muscles through exercises like gentle range-of-motion activities and weight-bearing play may help stabilize the joint and reduce future occurrences.^[1]^[40] At the community level, awareness campaigns integrated into pediatric guidelines emphasize non-physical handling techniques to prevent pulled elbow, with organizations like the American Academy of Pediatrics reinforcing education for parents and childcare providers. These initiatives promote routine counseling during well-child visits to highlight safe lifting and supervision practices, aiming to lower incidence rates in early childhood settings.^[38]^[41]

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