Pulled elbow

Pulled elbow (also known as a or nursemaid’s elbow or babysitter’s elbow) is a partial dislocation of the elbow. It happens when the radius bone in the lower arm (forearm) slips out of its normal position at the elbow joint, and is usually caused when a child’s outstretched arm is pulled or tugged suddenly.

Pulled elbow is a common injury affecting young children, usually those aged 1-4 years. It is most common among 2 to 3 year olds.

Symptoms

A child with a pulled elbow usually complains of pain as soon as the injury happens. After that they stop using their arm and refuse to bend the elbow because moving it is painful. Their arm will usually be limp by their side or, if they are sitting, supported in their lap.

The child is usually only distressed when trying to move the arm. The elbow is not usually swollen, bruised or tender to touch.

What causes a pulled elbow?

A pulled elbow happens when a child's outstretched arm is pulled suddenly, usually by an adult. It often happens when:

  • an adult or taller person pulls on a child’s hand or wrist to remove the child from a danger, for example when quicky crossing the road;
  • a child tries to pull away from an adult when holding hands;
  • a caregiver holds a child by the hand or wrist to help them walk or go up stairs and suddenly pulls upwards; or
  • a child is swung around by the hands or arms when playing.

The ligaments that hold the elbow joint together are not fully formed in young children, so only a small amount of force is needed to partially dislocate the elbow. In up to half of cases, the child and caregiver do not even remember the arm being pulled.

In some children the ligaments are especially loose, meaning that a pulled elbow injury can keep happening.

What happens to the elbow?

In a pulled elbow, the top of the radial bone (one of the 2 forearm bones) partially slips underneath the ligament that normally holds it in place. This results in the radius not being in the right position at the elbow joint. It becomes partially separated (dislocated) from the arm bone (the humerus).

Doctors refer to a pulled elbow as a subluxation of the radial head (subluxation means a partial or incomplete joint dislocation).

What should I do if my child dislocates their elbow?

If you think your child might have a dislocated elbow, they should be seen by a doctor straight away. You can take them to your GP (general practitioner) or the nearest hospital emergency department.

The sooner your child is treated, the easier it will be to repair the injury. If treatment is delayed it may become more painful to treat and recovery may take longer.

Tests and diagnosis

Pulled elbow is a common problem in young children and can usually be diagnosed based on the child’s symptoms and physical examination.

An X-ray is not usually required but may be done if your doctor suspects another injury, such as a fracture.

What is the treatment for pulled elbow?

A pulled elbow can usually be quickly fixed by a doctor or nurse, who will gently move the bones back into their normal position. The procedure is called a manual reduction, and can be done in the doctor’s rooms or hospital emergency department.

Manual reduction of a pulled elbow

Having any joint put back in place can be painful, and your child may become distressed, so try to keep them as calm as possible.

Your child will be asked to sit on your lap to have the manual reduction, which can be done in a couple of different ways. Both ways involve holding the elbow firmly and quickly rotating the forearm. The forearm may be rotated in an inward or outward direction, and the elbow may then be bent upwards. Often a ‘click’ will be heard when the radius slips back into place. Sometimes more than one try is needed to get the bones back into position.

If is not possible to do the manual reduction, X-rays will be needed to confirm the diagnosis and rule out any other problems. A reduction under a general anesthetic may be recommended in some cases where reduction has not been possible.

Once the elbow joint has been reduced, your child should not be in pain and should be happy to start using their arm again within a few minutes. If your child isn’t using their arm properly within a day or so, you should take them back to the doctor - it’s possible that the elbow may not have been properly reduced, or that it has partially dislocated again.

How long does a pulled elbow take to heal?

Pulled elbow is not a serious injury and usually does not cause long-term damage. Once it has been reduced your child should start using their arm as usual.

Preventing recurrences

Children who have had a pulled elbow injury are more prone to having the same injury again. The risk of a recurrence is highest in the month or so after the initial injury.

Try to be especially careful not to suddenly pull on the arm, and only pick your child up by placing your hands under their upper arms. Make sure anyone caring for your child knows not to pick them up by the wrists or arms.

References

1. Royal Children’s Hospital Melbourne. Pulled elbow (updated March 2018). https://www.rch.org.au/kidsinfo/fact_sheets/Pulled_elbow/ (accessed Sep 2018).
2. Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: Pulled elbow. https://www.rch.org.au/clinicalguide/guideline_index/Pulled_elbow/ (accessed Sep 2018).
3. Royal Australian College of General Practitioners (RACGP). Manipulation: subluxation of radial head (pulled elbow) (published October 2013). https://www.racgp.org.au/your-practice/guidelines/handi/interventions/children/manipulation-for-subluxated-radial-head/ (accessed Sep 2018).
4. 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. https://www.cochrane.org/CD007759/MUSKINJ_different-methods-manipulation-reducing-pulled-elbow-young-children (accessed Sep 2018).
5. BMJ Best Practice. Joint dislocation (updated 29 May 2018). https://bestpractice.bmj.com (accessed Sep 2018).
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