Pulled elbow

What is pulled elbow in kids?

Without getting into too many anatomic details, one of the ligaments that envelop the head of one of the bones of the arm shifts and is now located in the elbow joint.
Let us all remember that the forearm is the part between the elbow and the hand. The upper arm is the part between the shoulder and the elbow.
Please note the definition, this is not the case of a dislocated elbow, which is very pathologic and uncommon in children but a pulled elbow and displacement of a ligament only, that can be fixed and put back in its place using a short and relatively simple maneuver.

What causes pulled elbow in children and what doesn’t?

In fact, the action that causes pulled elbow in children is pulling of a child’s straightened arm. Imagine a child sitting on the floor and being pulled up by the arm to standing, or alternatively a sudden and strong pull of the forward outstretched arm trying to prevent a fall.
What doesn’t cause this condition? Local trauma or injury.
It’s important to understand the mechanism and identify it, mainly to avoid missing a real injury in the area of the elbow in which one shouldn’t attempt returning the pulled elbow to its place with the maneuver we will mention further on.
This almost exclusively occurs in children under the age of 5 years.

What are the signs of pulled elbow in children and how will the child behave?

This is how the child will act right after the elbow is pulled:
# Immediate pain and refusal to move that arm that will stay fixed close to the body with the arm dropped and the palm facing downwards.
# Inability to supinate the elbow. Supination is the outward rotation of the arm, meaning bringing the palm from a down-facing to up-facing position.
# The flexing and straightening of the elbow are possible but every movement of the arm may be painful.
# Usually, there’s no local swelling of the elbow. This is important mainly in cases when the mechanism of injury/pulling is unknown and the child doesn’t move the arm. If a sign of injury is noted and the child doesn’t move the elbow – do an X ray (and read here before).

When should medical attention be sought?

First of all, other local injuries should not be missed, mainly fractures. If you don’t have the exact information about the mechanism that caused the case and there’s no history of a typical arm pull, better get checked up.
Also in cases of direct injury to the elbow or near it, this is not pulled elbow and therefore you should get examined by a doctor and consider further work-up.
If there’s a typical patient history and findings for a dislocated elbow and you are not skilled in returning the ligament to its place, see a doctor that does it.
If there are local findings of local swelling or redness or warmth – you should go see a doctor.
If a long period of time has passed since the injury (more than several hours), you should be examined by a doctor. This is because at times, after a while, local edema develops and returning of the elbow is more challenging.
I will remind you, that after a first incidence of pulled elbow the child is prone to recurrence. That’s why many experienced parents already know to identify the typical pulling mechanism and the findings on physical examination.

What is the treatment and what should be expected following it?

Assuming a pulled elbow is in question, the treatment is a simple manipulation to return that ligament back in its place. There are two maneuvers that may be performed, you’re your permission, I will focus on the easier one of the two.
According to the pediatric text books, parents may be taught to return the ligament back in its place to prevent repeated medical care visits and reduce the child’s suffering.
However, do pay attention to the red flags that I’ve written before. Don’t try and return an injured elbow, try to return it only if the medical history and physical findings are clearly of a pulled elbow.
There’s no need for sedation during this manipulation and it usually takes only several seconds.

What is the procedure to return a pulled elbow to its place in children?

The child is sitting with the back toward one of the parents. Whoever is about to perform the manipulation should sit comfortably facing the child.
The parent holding the child should lend support by putting an arm over the upper arm about to be treated.
The person performing the maneuver should hold the child’s hand with their dominant hand and using the other wrap the fingers around the area under the elbow (the radius bone’s head). The hand holding the elbow area should not move.
The next step is outward rotation of the child’s hand and flexing the elbow (bringing the hand close to the area of the shoulder of the returned arm).
Sometimes a ‘click’ is felt (or even heard), announcing the return of the ligament to its place.
At this stage, if the treatment was successful, you may tell the child to take a little distance, and if indeed it was returned successfully, they will go back to using their arm normally within seconds or minutes.
It’s possible to offer the child a candy and ask them to take it with the treated hand.
If the manipulation was unsuccessful, it’s possible to try it several more times but you should rethink whether indeed a pulled elbow is at hand, or another pathology demanding more serious examination. It’s possible to place the arm in a sling and go to see the pediatrician.
After a successful return of the elbow to its place there’s no need for specific treatment. Avoidance of a repeated pull is advisable.

How may a recurrent event of pulled elbow be avoided?

Pulling of the children using the hand should be avoided. Better lift by pulling the area of the elbow or arm pit.
As I wrote above, children that had already experienced a pulled elbow are at risk for a repeated event. Such recurrent events, even if occur multiple times will not cause a long term problem. At a certain age, the bone grows and the risk for movement of the ligament is greatly reduced.

So, in conclusion, a common condition in pediatrics. Pediatricians who are skillful with the returning maneuver really like to treat this condition because the satisfaction is immediate and magic-like.
Parents may also learn to perform it but the most important thing is not to miss other conditions (mainly injuries) that require different care.