Pulled Elbow
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Direct answer
Nothing breaks in a pulled elbow — the radial head subluxates out from under a partially torn annular ligament, whose distal fibres slip into the radiohumeral joint. The history is a longitudinal tug on the arm of a child between one and four years: a parent swinging the toddler, pulling a sleeve through a door, or yanking the hand on the road. The child immediately refuses to use the arm, holds it slightly flexed and pronated, and points with the unaffected hand; tenderness is minimal over the lateral elbow. Radiographs are unnecessary when the story and posture are typical, and treatment is immediate closed reduction by the supination-flexion manoeuvre or hyperpronation — a click with brief crying, then use of the arm within minutes, is both diagnostic and curative. Recurrence happens in about a quarter, and parents are counselled against longitudinal traction.
What you must remember
- Mechanism: traction on an extended, pronated forearm in a 1-4 year old tears the distal annular ligament; the child's radial head is cartilaginous and the ligament relatively horizontal, permitting interposition.
- Presentation: arm held flexed 15-30 degrees and pronated, movement refused, no swelling or deformity, tenderness just distal to the lateral elbow.
- Diagnosis is clinical: radiographs reserved for atypical stories, swelling, point tenderness elsewhere, or failure to use the arm within 24-48 hours of reduction — plain films cannot show a cartilaginous subluxation.
- Reduction manoeuvres: supination then full flexion (traditional), or hyperpronation with elbow flexed — the click under the thumb predicts success; hyperpronation is less painful with comparable results.
- Recurrence: about 25 per cent, because the ligament needs weeks to heal and every fresh pull re-subluxates the head; brief splinting and, exceptionally, annular ligament reconstruction are described.
- Differential not to miss: lateral condyle fracture (swelling, crepitus, positive fat pad — needs radiograph and fixation), supracondylar fracture, and occult forearm fracture after genuine falls.
The two-minute consultation
A two-year-old is carried in with the right arm limp at her side, slightly bent and turned in; the father lifted her by that hand when she stumbled off a step two hours ago. She will not reach for a toy. There is no swelling or supracondylar tenderness. This is the clinical diagnosis, and the next act precedes imaging: the examiner grips the elbow with the thumb over the radial head, holds the wrist, and hyperpronates the forearm while flexing the elbow — feeling a click beneath the thumb. The child cries for half a minute and then, characteristically, reaches for the mother's phone with the same arm within ten minutes.
If she still refuses the arm a quarter-hour later, one repeat with supination-flexion suffices. If the arm remains unused at 24-48 hours despite a felt click, or the initial examination had swelling or bony tenderness, radiographs are ordered, because the presumed pulled elbow was actually a lateral condyle fracture, the mimicker with real consequences. Counselling closes the visit: no lifting or swinging by the hand, hold toddlers under the axillae, and expect one in four to return — recurrence is an unhealed ligament, not a treatment failure.
How the exam frames it
The stem is nearly always three ingredients — preschool child, longitudinal pull, arm held flexed and pronated — and the answer is reduction by supination-flexion or hyperpronation, with distractors of radiograph-first, splint, or arthrogram. Two higher-order points recur: why no X-ray (the radial head is unossified cartilage and the lesion ligamentous, so films are normal) and what exactly interposes (the distal annular ligament between the radial head and capitellum). The opposite trap: a child who fell directly on the elbow, with swelling, is a lateral condyle or supracondylar fracture until a film says otherwise — mechanism, not posture, separates them. In Indian family practice, the swing-by-the-hands habit and pulling children through crowds or off buses is the everyday source, so the hold-under-the-arms counsel is a genuinely useful exit line for the viva as well.
Frequently asked questions
What is the classic mechanism of a pulled elbow?
Longitudinal traction on the pronated, extended arm of a one-to-four-year-old, tearing the distal annular ligament and allowing it to interpose between the radial head and capitellum.
Which manoeuvres reduce a pulled elbow?
Supination followed by full elbow flexion, or hyperpronation with the elbow flexed — success is marked by a click under the examiner's thumb and rapid return of arm use.
Why are radiographs usually not needed?
The radial head is cartilaginous and the pathology ligamentous, so plain films are normal; imaging is reserved for atypical history, swelling, bony tenderness, or persistent non-use after reduction.
How often does a pulled elbow recur?
In roughly a quarter of children, because the annular ligament needs weeks to heal and renewed traction re-subluxates the head — recurrent cases may be splinted briefly for comfort.
Which fracture most closely mimics a pulled elbow?
The lateral condyle humerus fracture — swelling, crepitus and a positive fat pad with a true fall history should prompt radiographs, since missed displacement leads to non-union and cubitus valgus.