Pulled elbow

What is pulled elbow in kids?

Without going into too much anatomical detail, one of the ligaments that surrounds the head of one of the arm bones shifts and becomes lodged in the elbow joint.
Let’s remember: the forearm is the part between the elbow and the hand, while the upper arm is the part between the shoulder and the elbow.
Please note that this is not a case of a dislocated elbow, which is rare and more severe in children. Pulled elbow involves only the displacement of a ligament and can usually be corrected with a quick and relatively simple maneuver.

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

Pulled elbow in children is caused by pulling on a child’s straightened arm.
Imagine a child sitting on the floor being pulled up by the arm, or a sudden and strong tug on the outstretched arm to prevent a fall.
What doesn’t cause this condition? Local trauma or direct injury.
It’s important to understand the mechanism to avoid missing a true injury in the elbow area. In cases of actual injury, one should not attempt the maneuver to fix a pulled elbow, which we will describe later.
This condition occurs almost exclusively in children under the age of 5.

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

Here’s how a child typically behaves immediately after the elbow is pulled:
• Immediate pain and refusal to move the arm, which will be held close to the body, with the arm hanging down and the palm facing downward.
• Inability to supinate the forearm. Supination is the outward rotation of the arm — turning the palm from facing down to facing up.
• Flexing and straightening the elbow may still be possible, but any movement of the arm may cause pain.
• Usually, there is no visible swelling of the elbow. This is important when the mechanism of injury is unknown and the child refuses to move the arm. If signs of injury are present and the child isn’t moving the elbow, an X-ray should be done (read here first).

When should medical attention be sought?

First, it’s essential not to overlook other injuries, especially fractures. If the cause of the issue is unclear or there is no history of a typical arm pull, it’s better to get checked.
In cases of direct trauma to or near the elbow, this is likely not a pulled elbow. These cases require a medical evaluation and possibly further tests.
If there is a typical history and clinical signs of pulled elbow but you are not experienced with the maneuver, consult a physician who is.
If there are signs such as swelling, redness, or warmth around the elbow — see a doctor.
If several hours have passed since the injury, a doctor should evaluate the child. Over time, swelling may develop, making the repositioning maneuver more difficult.
Remember, after the first episode of pulled elbow, the child is more likely to experience recurrence. Many experienced parents recognize the signs and mechanism and act accordingly.

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

Assuming it is indeed a case of pulled elbow, the treatment involves a simple maneuver to return the ligament to its place. There are two techniques, but with your permission, I’ll focus on the simpler one.
According to pediatric textbooks, parents can be taught to perform this maneuver to prevent repeated doctor visits and reduce the child’s discomfort.
However, it’s crucial to pay attention to the red flags mentioned earlier. Never attempt this if the history or symptoms point to an actual injury.
The maneuver requires no sedation and typically takes only a few seconds.

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

The child should sit with their back against one of the parents. The person performing the maneuver should sit comfortably in front of the child.
The assisting parent supports the child by placing an arm over the upper arm to be treated.
The person performing the maneuver should hold the child’s hand with their dominant hand and use the other hand to wrap around the area just below the elbow (around the head of the radius bone). This hand must remain still.
Then, rotate the child’s hand outward and gently bend the elbow, bringing the hand toward the shoulder of the same arm.
Sometimes a click is felt (or heard), indicating the ligament has returned to its place.
If successful, encourage the child to step away and observe whether they begin using the arm again within seconds or minutes.
You can offer a candy and ask the child to take it with the treated hand.
If the maneuver doesn’t work, it may be repeated a few more times. If still unsuccessful, reconsider whether it’s truly a pulled elbow or another issue that requires further evaluation. You may place the arm in a sling and consult a pediatrician.
After a successful reduction, no specific treatment is needed. Avoid future arm-pulling to prevent recurrence.

How may a recurrent event of pulled elbow be avoided?

Avoid pulling children by their hands. Instead, lift them by supporting under the arms or by the upper arm.
As mentioned, children who have experienced pulled elbow are at higher risk for recurrence.
Even if this happens multiple times, it usually doesn’t cause long-term issues. As the child grows, the bones mature, and the ligament becomes more stable, significantly reducing the risk.

In conclusion, this is a common pediatric condition. Pediatricians experienced with the reduction maneuver enjoy treating it because the results are immediate and feel almost magical.
Parents can also learn how to perform the maneuver, but the most important thing is to avoid overlooking other conditions — particularly injuries — that require different care.