Paediatric Acute care Guidelines PMH Emergency Department

A pulled elbow is where there is partial subluxation of the radial head, with the orbicular ligament slipping off the end of the radius

Background

  • This is a common injury in toddlers 2-3 years of age (reported age range = 6 months – 7 years)

Pulled Elbow

 

Assessment

  • The history is central to the diagnosis
  • The child is often undistressed, but reluctant to use the arm, and cries if the arm is moved
  • The child usually holds the affected arm motionless, in a mid-prone position in front of the chest, kept still by the opposite hand

History

  • A sudden longitudinal pull or axial traction on the arm of an infant or toddler, while the arm is extended
  • Typically, the injury may occur when a parents grabs a child by the arm as the child is running away or falling
  • A typical history is central to the diagnosis
  • If the history is typical, and examination fits with the diagnosis, then X-Ray is not necessary
  • If the history or examination are not typical, then X-Rays should be done to exclude other injuries before attempting to manipulate the arm

Examination

  • There may be mild focal tenderness over the radial head, but generally there is no specific bony tenderness
  • Very gentle exclusive supination-pronation of an otherwise still forearm will cause distress (i.e. rotation of the radial head)

Investigations

  • No X-Rays are required unless the history is atypical

Management

Initial management

Reduction

First explain to the parents that there will be a brief moment of pain followed by complete relief of pain

Method 1:

  • With the elbow semi-flexed, grasp the forearm with one hand, and place the thumb of your other hand over the lateral aspect of the elbow
  • Supinate the forearm fully, and if not immediately successful, pronate fully
  • Reduction is almost always associated with a clicking sensation which is both heard and felt
  • If reduction hasn’t occurred at this stage, flex the elbow fully while keeping the elbow supinated

Method 2:

  • Flex the elbow and supinate the forearm as a single fluid movement

If reduction is successful, then the child should start using their arm freely a short while after reduction. No immobilisation is necessary after reduction.
If reduction has been unsuccessful, then an X-Ray should be done to exclude a different injury. If the X-Ray is normal, then reassure the parents that spontaneous reduction almost always occurs. A sling can be applied, appropriate analgesia given, and the child reviewed the following day.

References

  1. Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom-Smit LWA, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD007759. DOI: 10.1002/14651858.CD007759.pub4
  2. Aylor M, Anderson JM, Vanderford P, Halsey M, Lai S, Braner D. Reduction of Pulled Elbow. N Engl J Med 2014; 371:e32 November 20, 2014 DOI: 10.1056/NEJMvcm1211809 

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