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


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

Pulled Elbow


  • 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


  • 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


  • 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)


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


Initial management


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.



We want your feedback!

Help us provide guidelines that are useful to you, the clinician.

Give feedback here