Pulled elbow

Lore & Background

A pulled elbow occurs when the annular ligament, which wraps around the radial head, slips off and becomes trapped between the radius and humerus. The proximal attachment of this ligament to the radial neck is weaker in children than in adults, making it more easily torn. The radial head in young children is smaller and more disc-shaped relative to the neck, and is narrower proximally than the neck itself—this conical shape allows the ligament to slip off more easily; as the child grows, the radius becomes more cylindrical and the risk decreases.

Reader's Guide

A pulled elbow is a common injury in children aged 1 to 4 years, though it can occur up to age 7 and has been reported in infants under 6 months. The classic mechanism is a sudden pull on an extended arm, often from lifting or swinging a child by the arms, but falls and even rolling over in bed can cause it. Diagnosis is typically based on symptoms—such as the child refusing to use the arm, holding it slightly bent and palm down—and X-rays may be used to exclude fractures. Treatment involves reduction maneuvers: hyperpronation (moving the forearm palms down with straightening at the elbow) is more effective and less painful than supination followed by flexion. After successful reduction, the child returns to normal within minutes. The injury is rare in adults and older children due to changes in the radius shape with growth.

Did You Know?

• A pulled elbow is also called nursemaid's elbow or radial head subluxation.
• The injury can occur in infants under 6 months from rolling over in bed.
• Hyperpronation is a more effective and less painful reduction method than supination-flexion.
• There is no support for the assumption that a relatively small radial head predisposes young children to this injury.