Pulled Elbow in Children

What is Pulled Elbow?

Pulled Elbow or “Nursemaids Elbow” is common in young children between 1 and 4 years of age.It is rare beyond the age of 6 years. It is due to the annular ligament of the radial head becoming stretched and entrapped. There is usually a history of a pull on the affected arm, such as when a child tries to run off in a different direction when walking with the hand held by a parent.Sometimes the incident is unobserved or thought to be too trivial to have caused any injury. The child typically allows the arm to hang loosely by their side in a pronated position. They are usually undistressed unless the arm is moved.

Clinical Features

• The parents come with complaint of the child not using the affected limb
• here is usually a history of a pull on the affected arm, such as when a child tries to run off in a different direction when walking with the hand held by a parent. Although there may not be history of pull in half the cases
• Inspection: The child keeps the elbow in extension and the forearm in pronation and is distressed only on elbow movement. Usually there is no swelling, deformity or bruising of the elbow or wrist
• Palpation:  tenderness is usually absent
• Movements: marked resistance and pain with supination of the forearm.

Diagnosis

• Clinically established with a classic history and examination.
• X rays are unnecessary if there is a typical history and no visible swelling or deformity. If the child has a pulled elbow the X ray is normal. The child may have normal use of the arm on return from radiology since positioning by the radiographer may solve the problem.
• Plain radiographs are indicated when a differential diagnosis is suspected:
  • significant tenderness, swelling, bruising or deformity
  • reduction fails

Treatment

The treatment consists of reducing the ligament back to its original position

1. Have your child sit in a chair facing you or stand facing you. Ask an older sibling or adult to distract the child as that there is slight temporary pain when you treat a pulled elbow, and it will be easier to slip the ligament back into place if the child is relaxed.
2. You should support the elbow with one of your hands, placing your thumb over the radial head with some gentle pressure. Hold
   the child’s hand in your other hand as if you are shaking hands.
3. Fully supinate the forearm and then fully flex the elbow. A click is usually felt over the radial head either when the elbow is fully supinated or fully flexed. This is known as supination/flexion manoeuvre. Alternatively one can also try full pronation followed by flexion (pronation flexion manoeuvre).
4. A click is felt as the ligament moves back into the correct position. You may not always hear this happen.
5. Offer the child a toy to see if he or she will once again use his or her arm.  A good test for successful reduction is whether the child will actively reach for a toy at arms reach. Most children will use the arm normally within 5 minutes of the reduction. There may be residual pain, but overall, the child should feel much better.
6. Failure may be due to not putting the elbow through the complete range of motion. Repeat the reduction if the ligament is still out of place. This process should cure and treat your child’s pulled elbow in a few seconds, and they should be ready to play once again.
7. If the reduction has been delayed for 12 hours or longer the child may not use the arm normally for a longer period of time.  A sling ± backslab can be used for comfort, with review of whether the child will use the arm 24 hours late

Recurrant Pulled Elbow

Recurrances with pulled elbow are common till 3-4 years age. The repeat injuries are treated in the similar manner. Repeated subluxations do not produce long term problems. The problem generally disappears by 5 year age. Very rarely, in child with multiple recurrances the doctor may advice cast for 3 weeks

Updates in the management of pulled elbow

Obscure pathology of pulled elbow: dynamic high-resolution
ultrasound-assisted classificationHossam S. Diab • Manal M. S. Hamed •Yasser Allam

J Child Orthop (2010) 4:539–543

Of the 50 included children, 39 (78%) had intact,yet interposed annular ligament (classified as type I) and 11
(22%) had torn annular ligament (classified as type II). The latter underwent splinting for 7 days. Three out of the 50
children had recurrent subluxation and constituted falsenegative cases for the detection of torn ligament and represented
the reoccurrence rate of 6%.