Pulled Elbow: Causes, Symptoms, and Treatment

Overview

What is a pulled elbow?

A pulled elbow is also known as nursemaid’s elbow or radial head subluxation. It is a common injury in young children (usually between 1 and 4 years old) where one of the bones in the elbow (the radius) slips out of its normal position at the elbow joint. This happens when the annular ligament, which holds the radius in place, becomes temporarily displaced.

Other Names for Pulled Elbow:

• Nursemaid’s Elbow
• Radial Head Subluxation
• Dislocated elbow (in some contexts)

Understanding Pulled Elbow

Definition of Pulled Elbow

A pulled elbow, also known as nursemaid’s elbow or radial head subluxation, is a condition where the head of the radius (a bone in the forearm) slips partially out of the annular ligament, which normally holds it in place within the elbow joint. This injury commonly occurs in young children, particularly between the ages of 1 and 4.

Anatomy of the Elbow Joint

Three bones make up the elbow joint, creating a hinge joint:

• Humerus: The upper arm bone.
• Radius: One of the forearm bones, located on the thumb side.
• Ulna: The second forearm bone, located on the pinky side.

The radius fits into the annular ligament, which wraps around the radial head and holds it against the ulna. This ligament allows for the rotation of the forearm (like when turning the palm up or down) and is crucial in stabilising the elbow joint.

How Does a Pulled Elbow Occur?

A pulled elbow typically occurs when a child’s arm is extended and a sudden pulling force is applied. This pulling force can cause the head of the radius to slip out from under the annular ligament, resulting in a partial dislocation (subluxation). Since the ligaments in young children are still developing and relatively loose, this injury can occur more easily in them than in adults.

Common causes include:

• Pulling a child up by the hands or arms.
• Swinging a child by the arms.
• Sudden jerking or pulling while holding the child’s hand, such as when preventing a fall.

Injury mechanics: The radial head slips out of place because the child’s elbow is often extended and rotated during the forceful pull. This can prevent normal movement and cause pain, but the injury doesn’t typically cause swelling or obvious deformity.

Prevalence and Risk Factors

How Common Are Pulled Elbows?

Pulled elbows are very common, especially in young children. It is one of the most frequent orthopaedic injuries seen in children between the ages of 1 and 4 years old. The condition is more prevalent in this age group because their joints, ligaments, and bones are still developing, making them more susceptible to such injuries.

Who Is Most at Risk for Pulled Elbow?

The highest risk group includes:

• Children between 1 and 4 years old: At this age, the annular ligament is more loosely attached, allowing the radial head to slip out more easily.
• Girls: Studies show that pulled elbows are slightly more common in girls than boys.
• Toddlers: Young children who are active and often held by the hand or lifted by caregivers are most susceptible.

Risk Factors:

• Laxity of Ligaments: Children’s ligaments are more flexible and underdeveloped compared to adults, making subluxation more likely.
• Size and Shape of Bones: The radial head in young children is smaller and rounder, making it easier for the ligament to slip over it.
• Activities Involving Arm Pulling: Any sudden pulling on the child’s arm, such as lifting, swinging, or jerking, increases the risk of a pulled elbow.

Pulled elbows are rare after the age of 5 as the ligaments and bones become stronger and more stable.

Symptoms and Causes

What Causes a Pulled Elbow?

A pulled elbow occurs when the radial head (a bone in the forearm) slips out of its normal position in the annular ligament that holds it in place within the elbow joint. The main cause is a sudden pulling or yanking force applied to an extended arm, which can displace the radial head. Common scenarios include:

• Pulling a child up by the arms: When a caregiver lifts a child by their hands or arms.
• Swinging a child by the arms: Swinging a child in a playful manner by holding their hands can lead to injury.
• Sudden jerks or tugs: Jerking or pulling a child’s arm to prevent a fall or when the child resists being held.
• Falls: In some cases, the injury can result from a fall where the child’s arm is outstretched.

What Are the Symptoms of a Pulled Elbow?

The symptoms of a pulled elbow are often easy to recognise, especially in young children:

• Sudden Pain: The child will usually experience immediate pain in the elbow or forearm.
• Limp Arm: The child may hold their arm straight or slightly bent and close to their body, avoiding any movement. They may refuse to use the arm.
• Reluctance to Move: The child may refuse to move the affected arm and avoid using it for activities like grabbing, lifting, or playing.
• No Swelling or Bruising: Typically, there is little or no visible swelling, bruising, or deformity, which can make it difficult to spot at first glance.

Can Pulled Elbow Occur in Adults?

Pulled elbow is extremely rare in adults. This condition primarily affects young children because their bones and ligaments are still developing. By the time a person reaches adulthood, the radial head and annular ligament become stronger and more secure, making it highly unlikely for the radial head to slip out of place.

In adults, elbow injuries are more likely to involve fractures or ligament tears due to the increased strength and rigidity of the joint structures.

Diagnosis and Tests

A pulled elbow is typically diagnosed through medical history and physical examination. The medical provider will ask about how the injury occurred (such as a sudden pull or jerk on the arm) and assess the symptoms, especially whether the child avoids using the arm or holding it in a protective posture.

Steps in Diagnosis:

• History of the Injury: The healthcare provider will ask about the incident leading to the injury, such as if there was a sudden pull, fall, or lifting event involving the arm.
• Physical Examination: The doctor will gently examine the elbow and forearm, checking for pain, tenderness, or any reluctance by the child to move the arm. The absence of swelling or bruising often suggests a pulled elbow rather than a fracture.
• Arm Movement Test: The child may be asked to try to move the arm. In most cases, the child will avoid using the arm due to discomfort, holding it limply at their side.

What Tests Might Be Used to Confirm a Pulled Elbow?

In most cases, a pulled elbow is diagnosed based on clinical history and examination, imaging or other tests are typically not required. However, X-rays or other tests may be used if:

• The cause of the injury is unclear.
• There is concern about fractures or other injuries.
• The injury does not improve after an initial treatment or reduction attempt.

X-rays:

• Purpose: To rule out fractures or other bone injuries if the diagnosis of a pulled elbow is uncertain.
• Usage: While X-rays can show fractures or dislocations, they usually appear normal in cases of a simple pulled elbow because it involves ligament displacement rather than bone damage.

The staff at Access Ortho are specialists in musculoskeletal injuries such as Pulled Elbows. They will provide a thorough assessment and treatment plan. Contact Access Ortho for a rapid appointment if you have concerns about your child’s elbow. 

Specific Considerations

Pulled Elbow in Children vs. Adults

• Children:
  • Common in Ages 1 to 4: Pulled elbow, or radial head subluxation, is most frequent in children between 1 and 4 years old due to the looseness of their ligaments and the small, round shape of the radial head, which makes it easier to slip out of the annular ligament.
  • Ligament Flexibility: Children’s ligaments are more flexible, and the annular ligament is not as tightly attached as it is in adults, making subluxation more likely.
  • Injury Trigger: In young children, the injury typically occurs due to sudden pulling, jerking, or swinging of the arm.
  • Treatment: Simple manipulation by a healthcare provider usually fixes the problem with immediate relief and minimal recovery time.
• Adults:
  • Rare: Pulled elbow is extremely rare in adults because the ligaments and bones of the elbow joint are stronger and more developed. The radial head in adults is more secure within the annular ligament, and subluxation is less likely.
  • Injuries in Adults: Adults are more prone to fractures, dislocations, or ligament tears in the elbow due to the rigidity and strength of their bones and ligaments.
  • Different Mechanism: Adults may experience different elbow issues, such as radial head fractures, due to trauma, falls, or overuse, but these injuries involve bone or ligament damage rather than subluxation of the radial head.

Differentiating Pulled Elbow from Other Elbow Injuries

It is important to rule out other injuries when considering a pulled elbow. 

• Pulled Elbow (Radial Head Subluxation):
  • Cause: Sudden pull or jerk of the arm in young children.
  • Symptoms: The child holds the arm in a limp position and avoids using the arm, with no swelling, bruising, or deformity.
  • Age Group: Primarily occurs in children under 5 years old.
  • X-rays: Typically show no abnormalities, as the injury involves ligament displacement, not bone damage.
• Elbow Fractures:
  • Cause: Often due to trauma, falls, or direct blows.
  • Symptoms: Severe pain, visible swelling, bruising, and inability to move the arm. There may be a deformity in severe fractures.
  • Age Group: This can occur at any age.
  • X-rays: This will show a break or crack in the bone.
• Elbow Dislocation:
  • Cause: Usually caused by trauma, such as falling on an outstretched arm.
  • Symptoms: Severe pain, obvious deformity of the elbow joint, and inability to move the arm.
  • Age Group: More common in adults and older children.
  • X-rays: Will show that the bones of the elbow are out of alignment.
• Ligament Injuries (Sprains):
  • Cause: Overstretching or tearing of the ligaments from a sudden movement or overuse.
  • Symptoms: Pain, swelling, and difficulty moving the elbow, but without the severe deformity seen in dislocations or fractures.
  • Age Group: This can occur at any age, especially in athletes.
  • X-rays: May not show damage, but an MRI can be used to assess ligament injuries.

In summary, a pulled elbow is distinguished from other elbow injuries by its occurrence in young children, lack of swelling or deformity, and the specific mechanism of injury. Other injuries like fractures and dislocations involve different mechanisms and usually present with more obvious physical signs such as swelling, bruising, or joint deformity. Access Ortho will provide a thorough examination for an accurate diagnosis. 

Management and Treatment

How Is a Pulled Elbow Treated?

The primary treatment for a pulled elbow (radial head subluxation) is a manual reduction. It involves gently moving the arm to relocate the radial head back into its correct position within the elbow joint. This procedure is quick and typically results in immediate relief for the child. In most situations, this reduction can be done at Access Ortho. On occasion, a referral may be required if it is deemed inappropriate to do this in the clinic. 

There are two main techniques used to treat a pulled elbow:

• Hyperpronation Technique (Preferred)
• Supination and Flexion Technique

What Is the “Hyperpronation” Technique?

The hyperpronation technique is one of the most effective methods for treating a pulled elbow. It involves rotating the child’s forearm inward (pronating) while applying gentle pressure over the radial head.

Steps in the Hyperpronation Technique:

• The healthcare provider stabilises the child’s elbow with one hand.
• With the other hand, they hold the child’s forearm and rotate it inward (pronation) while applying pressure to the radial head.
• A gentle “click” or “pop” may be felt or heard as the radial head slips back into its normal position.

The hyperpronation method is often preferred because it is considered faster, more reliable, and less painful compared to other techniques.

Supination and Flexion Technique (Alternative)

Another method is the supination and flexion technique, where the forearm is first turned outward (supinated) and then the elbow is flexed (bent). However, this method is sometimes more uncomfortable for the child and may be less successful than hyperpronation.

When Is Medical Intervention Necessary?

Medical intervention is necessary if:

• The injury is suspected to be a pulled elbow. It is important to note that the reduction technique should only be performed by a healthcare professional to avoid causing further damage. 
• Home treatments do not resolve the issue: If parents attempt to move the arm and the child continues to avoid using the arm or complains of pain, professional treatment is needed.
• Multiple attempts fail: If the radial head doesn’t relocate after the initial reduction, a medical evaluation (including possible X-rays) may be required to rule out other injuries like fractures.
• Other symptoms arise: If there is significant swelling, bruising, deformity, or if the child experiences ongoing pain, it could indicate a more serious injury, such as a fracture or dislocation.

After the successful reduction, the child usually regains normal use of the arm within minutes. If the injury is recurrent, the caregiver may need advice on preventing future occurrences. Access Ortho will assess your child’s elbow and determine if a reduction is required. A reduction may be done in the clinic, or a referral will be arranged if required. 

Prevention

Can a Pulled Elbow be prevented?

Pulled elbows can often be prevented by using caution during activities that involve lifting or playing with young children. Since pulled elbows occur due to sudden, forceful pulls on the arm, taking steps to avoid these motions can significantly reduce the risk.

Safe Ways to Lift and Play with Children

To prevent pulled elbows, it’s important to gently handle children’s arms and avoid pulling, yanking, or jerking. Here are some tips:

1. Avoid Lifting by the Arms or Hands

• Never lift or swing a child by their hands, wrists, or forearms. This is the most common cause of pulled elbows. Instead, lift the child by supporting them under the arms or around the torso.

2. Support the Child’s Body When Playing

• When playing games like spinning or swinging, always hold the child under their armpits or around the waist. This distributes the weight and reduces strain on their arms and elbows.

3. Avoid Jerking Movements While Walking

• When holding a child’s hand while walking, avoid sudden jerks or pulls, especially if they trip or resist moving. If a child stumbles, try to support their body rather than pulling their arm to catch them.

4. Educate Other Caregivers

• Ensure that anyone caring for your child (such as relatives, babysitters, or daycare workers) understands the importance of lifting and playing with children safely. They should also avoid tugging on the child’s arms.

Following these simple precautions can help prevent pulled elbows and ensure safe and playful interactions with young children.

Outlook / Prognosis

What Is the Recovery Time for a Pulled Elbow?

The recovery time for a pulled elbow is typically very short. After the healthcare provider performs a successful reduction (relocating the radial head), children often regain full use of their arm within minutes to a few hours. In most cases:

• Immediate Relief: The child usually experiences immediate relief from pain following the procedure.
• Normal Function: They will often begin using their arm normally shortly after, with no need for extended recovery or physical therapy.

Are There Any Long-Term Effects of Pulled Elbow?

In most cases, there are no long-term effects from a pulled elbow. Once treated, the injury usually resolves completely without causing future problems. However, some considerations include:

• Recurrent Pulled Elbows: The injury can recur in some children, especially those under 5 years old, because their ligaments are still developing. Children who have experienced one pulled elbow have a slightly higher risk of having another until their ligaments strengthen as they grow.
• No Permanent Damage: Pulled elbows do not cause lasting joint or ligament damage. As the child’s joints and ligaments mature, they will become less susceptible to this injury.

Overall, a pulled elbow is a minor, easily treatable injury with a quick recovery and no expected long-term complications. However, it is important to seek medical care to ensure other injuries are not missed. Access Ortho offers rapid appointments for orthopaedic injuries such as Pulled Elbows.

When to Seek Medical Care

When Should I Take My Child to the Doctor for a Possible Pulled Elbow?

You should take your child to the doctor if you suspect a pulled elbow, especially if:

• Sudden refusal to use the arm: The child suddenly avoids using one arm, holds it limp, or keeps it close to their body after a tug or pull.
• Pain or discomfort: The child shows signs of pain when trying to move the arm, although they may not cry constantly.
• No visible swelling or bruising: There is no significant swelling, bruising, or deformity, which often points to a pulled elbow rather than a fracture or dislocation.
• Lack of improvement: If your child does not regain normal use of their arm within a short time after the injury, a visit to the doctor is necessary to confirm the diagnosis and perform a reduction.

What Are the Signs of a More Serious Elbow Injury?

Signs that may indicate a more serious elbow injury (such as a fracture or full dislocation) include:

• Severe pain: The child cries or complains of significant pain, especially with any movement.
• Visible swelling or bruising: Swelling or bruising around the elbow or forearm is a sign of trauma that may involve bones or soft tissues.
• Obvious deformity: The elbow or arm appears bent, misshapen, or out of alignment, indicating a possible fracture or dislocation.
• Inability to move the arm: The child is completely unable to move the arm or holds it still in a very protective position.
• Numbness or weakness: The child complains of numbness or tingling, or has weakness in the arm, hand, or fingers, which could indicate nerve or vascular injury.

If any of these signs are present, seek immediate medical attention. They may be an indication of a more serious injury that requires urgent care, such as imaging, splinting, or surgery. Access Ortho offers rapid appointments for children and adults’ upper and lower limb injuries and specialises in orthopaedic care. 

What is an Orthopaedic Clinic?

An orthopaedic clinic, such as Access Ortho, is a medical facility that focuses on diagnosing, treating, and managing musculoskeletal conditions. These include issues related to the bones, joints, muscles, tendons, and ligaments. Access Ortho offers orthopaedic care for all acute upper and lower limb injuries.

 Orthopaedic clinics may offer:

• Diagnostic referral: X-rays, MRI, and other imaging studies.
• Treatment Options: Non-surgical treatments such as casts, splints, crutches, referral to physiotherapy and referral for surgical interventions if required. 

Many Urgent Care clinics and Emergency Departments offer care for all injuries and illnesses and are therefore not specialists in orthopaedic injuries. Access Ortho only offers care for acute orthopaedic injuries such as fractures, sprains and strains. They are experts in orthopaedic care, ensuring your assessment and treatment plan offers specialist care. 

Role of Orthopaedic Specialists in Treating Pulled Elbow

Orthopaedic specialists play a key role in diagnosing and treating a pulled elbow. Their responsibilities include:

• Diagnosis: Confirming the presence of a pulled elbow through a physical examination and, if needed, imaging to rule out other injuries.
• Reduction: Performing the manual reduction technique (such as hyperpronation) to realign the radial head in the elbow joint.
• Follow-Up Care: This involves providing instructions for care after the reduction, monitoring for complications, and advising on preventing future occurrences.
• Education: Educating parents and caregivers on safe handling and play practices to reduce the risk of recurrence.

Access Ortho is staffed by orthopaedic surgeons and orthopaedic nurse practitioners, ensuring high care for all our patients. 

What to Expect During an Orthopaedic Consultation

During an orthopaedic consultation for a pulled elbow, you can expect the following:

• Medical History:
  • The specialist will ask about how the injury occurred, symptoms, and the child’s general health and activity level.
• Physical Examination:
  • The specialist will examine the child’s arm and elbow to assess pain, movement, and positioning. They will check for signs of a pulled elbow or other injuries.
• Diagnosis:
  • If a pulled elbow is suspected, the specialist may perform a manual reduction in the office. If the diagnosis is uncertain or if the injury does not improve with reduction, imaging (like X-rays) may be recommended to rule out fractures or other injuries.
• Treatment:
  • The specialist will explain the reduction procedure and perform it if needed. They will provide immediate relief and check the arm’s function afterwards.
• Follow-Up Instructions:
  • You will receive information on how to care for the child’s arm, signs to watch for, and advice on activities to avoid. They may also suggest follow-up visits to monitor recovery.
• Education:
  • The specialist will offer advice on preventing future pulled elbows, including safe ways to lift and play with children.

The consultation aims to ensure proper treatment and prevent future issues, providing peace of mind and effective care for the child’s musculoskeletal health.

Commonly Asked Questions

Can a pulled elbow heal on its own?

A pulled elbow can heal on its own after a healthcare professional properly realigns (reduces) the radial head. Once the elbow is relocated, children typically experience immediate relief and resume normal function quickly.

How painful is a pulled elbow?

A pulled elbow is painful, but the pain is usually moderate. It often occurs suddenly and is typically localised around the elbow. The child may exhibit discomfort when moving the arm but usually experiences significant relief following the reduction.

Can a pulled elbow happen more than once?

A pulled elbow can occur more than once, especially in young children with developing ligaments. Children who have had one pulled elbow are at a higher risk for recurrence until their ligaments become more mature.

Is a pulled elbow the same as nursemaid’s elbow?

A “pulled elbow” and “nursemaid’s elbow” are different names for the same condition. Both terms refer to radial head subluxation. This is when the radial head slips out of the annular ligament in young children.

How long does it take for a pulled elbow to heal?

Recovery is typically very quick. Once a pulled elbow is properly treated, children often regain full use of their arm within minutes to a few hours. The healing process is usually immediate, with no extended downtime required.

Can adults get a pulled elbow?

Pulled elbow is extremely rare in adults. The condition is specific to young children due to the flexibility of their ligaments and the developmental stage of their bones. Adults are more likely to experience other types of elbow injuries.

What’s the difference between a pulled elbow and a dislocated elbow?

Pulled elbow (radial head subluxation) involves the radial head slipping out of place within the annular ligament, usually without visible deformity. A dislocated elbow involves a complete dislocation of the elbow joint, where the bones are out of alignment, often accompanied by visible deformity, significant pain, and swelling.

How can I comfort my child with a pulled elbow?

Comfort measures include reassuring the child and gently supporting their arm. After the reduction procedure, provide comfort and distraction with activities they enjoy. The pain typically subsides quickly, so offer comforting words and ensure they are comfortable.

What Happens if a Pulled Elbow Is Not Relocated Rapidly?

If a pulled elbow is not relocated quickly, it can lead to persistent pain, difficulty using the arm, and potential complications like inflammation or ligament stress. There is also an increased risk of future injuries and possible delays in recognising other serious conditions. Prompt relocation usually provides immediate relief and prevents these issues.

When can my child return to normal activities after a pulled elbow?

Normal activities can usually be resumed almost immediately after a pulled elbow is treated. The child often regains full use of their arm within minutes, so they can typically return to regular activities and play without restriction.