Pulled elbow
A toddler pulled by the hand who won't use the arm. No swelling? Reduce with hyperpronation; no X-ray needed.
A 2-year-old girl won't use her right arm after her father swung her by the hands in the park an hour ago. She cried at once, then stopped. She holds the arm by her side, slightly bent at the elbow, with the palm turned down. There is no swelling, no bruising, and no tenderness when you gently feel along the collarbone, upper arm, elbow, forearm and wrist. She cries when you try to turn her palm up.
Do you X-ray first, and how do you reduce it?
- Fall, swelling, bruising or bony tendernessX-ray first: think fracture (supracondylar, clavicle, forearm).
- Story doesn't fitConsider non-accidental injury and involve a senior.
- Typical story with no swellingReduce without X-ray.
- Hyperpronation firstOften more successful and less painful than supination-flexion.
- Feel for a clickOver the radial head as it reduces.
- Watch for useMost children use the arm within 15–30 minutes.
- AdviseAvoid lifting or swinging by the hands, it can happen again until about age 5.
- Swelling, bruising or bony tenderness
- Fall or unclear story
- Fails two reduction attempts
- Concerns about how the injury happened
- Older child (fracture more likely)
- Supracondylar fracture
- Clavicle fracture
- Forearm fracture
- Non-accidental injury
- Septic arthritis (fever, swelling)
| Age | Usually 1–4 years (up to about 6) |
| Mechanism | Sudden pull on the hand or wrist with the elbow straight |
| Hyperpronation | Hold the elbow, firmly turn the forearm palm-down further |
| Supination-flexion | Turn the palm up and bend the elbow fully in one movement |
| Not using arm after 2 attempts | X-ray and review |
| Pain relief | Paracetamol 15 mg/kg or ibuprofen 10 mg/kg if needed |
Check every dose against a current drug reference and your hospital protocol.
On this page
What is a pulled elbow?
In young children the annular ligament around the radial head is loose. A sudden pull on the hand with the elbow straight lets the radial head slip partly out, trapping the ligament in the joint. It is the commonest elbow injury in toddlers and is very easy to treat.
History
- Mechanism: pulled up by the hand (lifting over a kerb, swinging, stopping from running off), sometimes a fall or rolling over.
- Cried at once, then stopped using the arm.
- Holds the arm by the side, slightly bent, palm down (pronated).
- No fall onto the arm, no swelling.
- Previous pulled elbows.
Examination
- LookArm held slightly bent and palm down; no swelling, bruising or deformity.
- Feel gentlyClavicle, humerus, elbow, forearm, wrist: no bony tenderness.
- MoveTurning the palm up hurts; the child won't lift the arm.
- Story checkDoes the story fit the child's age and the injury?
Do I need an X-ray?
- Reduce now
- no X-ray
- X-ray first
- think fracture
- Senior
- consider safeguarding
Reduction
- Explain and positionChild on the parent's lap facing you. Warn it will hurt for a moment.
- Hold the elbowYour thumb over the radial head (outer side of the elbow).
- HyperpronationFirmly turn the forearm palm-down beyond the normal range.
- Or supination-flexionTurn the palm up, then bend the elbow fully, in one smooth movement.
- Feel for the clickThen let the child play with a toy; reassess in 15–30 minutes.
- Hyperpronation works more often first time and is less painful.
- If the first method fails, try the other.
- After 2 failed attempts: X-ray, and if normal, a sling and review in a few days (it often reduces by itself).
After reduction
- Most children start using the arm within 15–30 minutes, reaching for a toy.
- No sling needed if the child is using the arm.
- Advise parents to lift by the body or under the arms, not by the hands or wrists, until about age 5.
- It can recur; parents can be reassured that it's easy to treat.
Common mistakes
- Reducing a "pulled elbow" that is actually a supracondylar fracture after a fall.
- X-raying every typical pulled elbow.
- Giving up after one method.
- Sending the child home before checking they use the arm.
- Not considering how the injury happened.
Frequently asked questions
What is a pulled elbow?
Slipping of the radial head partly out of the annular ligament after a sudden pull on a young child's arm.
Does a pulled elbow need an X-ray?
Not if the story is typical and there is no swelling, bruising or bony tenderness.
How is a pulled elbow reduced?
Hyperpronation (turning the palm down firmly) or supination-flexion (turning the palm up and bending the elbow fully), with a thumb over the radial head.
Can a pulled elbow happen again?
Yes, until about age 5. Lift children by the body, not by the hands or wrists.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 2-year-old won't use her arm after being swung by the hands. No swelling or bony tenderness. What is the next step?
Answer: Reduce by hyperpronation. Hyperpronation or supination-flexion; the child usually uses the arm within 30 minutes.
- Plaster cast: No.
- Refer to orthopaedics: Not needed.
- Sling for 3 weeks: No.
- X-ray first: Not needed with a typical story.
2. Which structure is involved in pulled elbow?
Answer: Annular ligament. The radial head slips partly out of the annular ligament.
- Olecranon: No.
- Biceps tendon rupture: No.
- Medial epicondyle: No.
- Ulnar collateral ligament: No.
3. When should a child with suspected pulled elbow be X-rayed first?
Answer: After a fall or swelling. These features suggest a fracture.
- Only if crying: No.
- Only if over 1 year: Not the criterion.
- Never: Sometimes needed.
- Always: Not needed with a typical story.
4. A 3-year-old cries and won’t use her arm after being swung by the hands; she holds the arm pronated and slightly flexed with no swelling or bruising. What is the management?
Answer: Reduce by supination and flexion. Pulled elbow (nursemaid’s elbow): radial head subluxation through the annular ligament from sudden traction on the extended pronated arm; ages 1–4; child refuses to use the arm, holds it pronated; no swelling. Reduction: supination with flexion (or hyperpronation) — often a click, then use returns within minutes. X-ray only if atypical (trauma, swelling, failure to reduce). Advise parents to avoid pulling by the arms.
- Above-elbow cast for 3 weeks: This is not a fracture.
- Urgent X-ray and ORIF: Pulled elbow typically needs no X-ray.
- Sling and review in 2 weeks: A quick reduction is curative; a sling is not needed.
5. A weightlifter feels a sudden pop in the front of his elbow. His upper arm shows a bulge ("Popeye" sign) and supination is weak when the elbow is flexed. The torn muscle inserts into which structure?
Answer: Radial tuberosity. Biceps brachii inserts into the radial tuberosity and, through the bicipital aponeurosis, into the deep fascia of the forearm. It is a powerful supinator, especially with the elbow flexed, and a flexor of the elbow. A distal biceps rupture causes weakness of supination and flexion.
- Coronoid process of the ulna: Insertion of brachialis, a pure elbow flexor that does not supinate.
- Olecranon: Insertion of triceps, the elbow extensor.
- Lateral epicondyle: Common extensor origin.
- Medial epicondyle: Common flexor origin.
6. Which tendon passes through the shoulder joint cavity, enclosed in a synovial sheath?
Answer: Long head of biceps. The long head of biceps arises from the supraglenoid tubercle and runs within the joint capsule over the humeral head, enveloped in synovial membrane, then through the intertubercular groove under the transverse humeral ligament. It helps stabilise the humeral head. The short head arises from the coracoid process (outside the joint). Supraspinatus passes above the joint (subacromial bursa); long head of triceps arises from the infraglenoid tubercle.
- Short head of biceps: Coracoid origin, extracapsular.
- Supraspinatus: Above the capsule; rotator cuff.
- Long head of triceps: Infraglenoid tubercle, outside.
- Coracobrachialis: Coracoid, outside.
References and dose sources
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.