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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 not distressed unless the arm is moved, passive elbow flexion is usually allowed but supination causes pain.
If there is any deformity at the elbow an alternative diagnosis (e.g. fracture or osteomyelitis) is more likely, in which case obtain further investigations prior to any attempts at reduction.
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.
If an X-ray has been requested the child may have normal use of the arm on return from radiology as positioning by the radiographer may result in reduction.
There are 2 methods of reduction - 'hyperpronation' or
'supination then flexion'. The 'hyperpronation' method has been
shown to be more successful and possibly less painful.
We recommend using the 'hyperpronation' method (which can be followed immediately by 'supination then flexion' method if desired).
If the first attempt is unsuccessful, repeat the manoeuvre after 15 minutes.
Reduction is usually simple although briefly distressing for the child - warn the parents beforehand. If there have been previous unsuccessful attempts at reduction consider using continuous nitrous sedation for further attempts at reduction. This should be discussed with a senior clinician before proceeding. Refer to the nitrous oxide guideline for ADHB staff only
Support the child's elbow flexed at 90 degrees with one hand, with gentle pressure from your thumb over the radial head and immobilising the humerus. Hold the child's hand with your other hand as if shaking hands. Turn the palm down (pronation) and straighten the elbow while maximally pronating the forearm. You may feel a click over the radial head
Supination and Flexion Method
Support the elbow flexed at 90 degrees with one hands, with gentle pressure from your thumb over the radial head. Hold the child's hand in your other hand as if you are shaking hands. Fully supinate then fully flex the elbow. A click is usually felt over the radial head either when the elbow is fully supinated or fully flexed. Failure may be due to not putting the elbow through the complete range of motion.
Most children will use the arm normally within 5-10 minutes of
the reduction. In this case the child may be discharged with no
follow up required. A good test for successful reduction is whether
the child will actively reach for a toy at arms reach.
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.
Occasionally it is unclear whether reduction has been successful. In these cases consider other possibilities (e.g. supracondylar fracture or osteomyelitis). A sling ± backslab can be used for comfort, with review of whether the child will use the arm 24 hours later. If the child is still not using the arm normally at this stage obtain X-rays (if not already performed) and consult the Orthopaedic team.
Provide caregivers with the "Pulled Elbow" advice sheet from CED (below).
Information for Families
Click on the image below to view a downloadable pdf information sheet
Bek D, Yildiz C, Köse O, Sehirlioğlu A, Başbozkurt M. Pronation
versus supination maneuvers for the reduction of 'pulled elbow': a
randomized clinical trial. Eur J Emerg Med. 2009
Charles G. Macias, MD*, Joan Bothner, MD‡, Robert Wiebe, MD. A Comparison of Supination/Flexion to Hyperpronation in the Reduction of Radial Head Subluxations. Pediatrics Vol. 102 No. 1 July 1, 1998, pp. e10
Krul M, van der Wouden JC, van Suijlekom-Smit LWA, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD007759. DOI: 10.1002/14651858.CD007759.pub3
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- Date last published: 20 February 2017
- Document type: Clinical Guideline
- Services responsible: Children’s Emergency Department
- Author(s): Mike Shepherd, Richard Aickin, Julie Scott
- Editor: Greg Williams
- Review frequency: 2 years
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