elbow subluxation; annular ligament displacement; radial-head subluxation; pulled elbow

Epidemiology

• common orthopedic injury in children
• incidence of emergency department visits is 2.7 per 1000 in children <18 years of age.2
• median age at presentation is 2 years
• injury is unique to infants & young children

Pathology

• the radial head is less bulbous than it is in older persons & may easily become displaced
• during forceful longitudinal traction, such as when a child is pulled or lifted by the arm, the radial head is pulled underneath the annular ligament
• the ligament then becomes entrapped proximal to the radial head at the level of the radiocapitellar joint

Clinical manifestations

• pseudoparalysis:
  • child voluntarily keeps arm still to minimize discomfort
• pain with movement, most often related to supination & pronation rather than to flexion & extension
• in most cases there will be tenderness to palpation on the lateral side of the elbow
• normal-looking elbow without effusion, bruising, or obvious deformity.

Radiology

• radiographs almost always normal
  • positioning the elbow in preparation for radiography is often therapeutic in reducing the displacement

Management

• reduction of subluxation is a safe outpatient procedure*
  • supination technique
    • with the child facing you, clasp both the hand & elbow of the affected arm
      • your fingers or thumb should overlie the radial head
    • supinate & flex the forearm until you feel the ligament move back into position
    • you may feel or hear a click as the ligament is reduced
    • if reduction is successful, the child should be pain free & able to move the arm normally in 5 to 30 minutes
  • hyperpronation technique
    • with the child facing you. clasp the hand of the affected arm as you would in a handshake
    • use your free hand to support the child's elbow
    • hyperpronate the child's wrist
    • you may feel or hear a click as the ligament is reduced
    • if reduction is successful, the child should be pain free & able to move the arm normally in 5 to 30 minutes

* ref has a video illustrating reduction of elbow subluxation

More general terms

• subluxation

Additional terms

• elbow (cubital joint)