Pulled Elbow (A Child Unable to Lift Their Arm)

The elbow is where the upper arm bone (humerus) meets the two forearm bones (radius and ulna). The upper end of the radius is held in place by a ring-shaped band, the annular ligament. In young children this ligament is still lax, and the radial head has not yet developed its full rounded shape.

A sudden pull on the arm may cause the radial head to slip partly beneath this ring-shaped ligament; trapped ligament tissue causes pain and the child stops using the arm. This is commonly called pulled elbow, medically radial head subluxation. There is no bone fracture or complete joint dislocation.

It is most common at ages 1–4; frequency decreases markedly after 5–6 as the ligament strengthens. It is a frequent cause of "cannot lift the arm" in young children brought to AC CLINIC in Ordu and usually resolves quickly after correct assessment.

It often follows a very simple movement, and families may blame themselves, although it reflects young children's anatomy. The most common mechanisms are:

• Pulling a child upwards by the hand or lifting them by the arm on stairs or a kerb
• Swinging children in the air by their hands or spinning them around
• A child being caught by the hand while falling and suddenly hanging from it
• Pulling the arm forcefully while putting on a jacket or jumper
• Sometimes rolling onto the arm while lying down or a minor fall, without obvious pulling

The distinguishing feature is the child's refusal to use the arm. Common findings include:

• The child suddenly stops using the arm and will not pick up a toy with that hand
• The arm rests close to the body, the elbow slightly bent and the palm facing down
• The child cries when the elbow is moved and does not want the arm touched
• There is usually no obvious swelling, bruising or deformity at the elbow
• The child may be calm while keeping the arm still, leading the family to underestimate the problem

The child should be seen by a doctor. Do not try manoeuvres described online or by others as 'turn it this way to put it back': a child who is not using an arm may have a fracture or another injury, and blind manipulation can cause harm.

Until the child is seen, do not force, pull or rotate the arm. Leave it in a comfortable position, supported close to the body. Be cautious about food and drink until medical advice is obtained, as further assessment may be needed.

The clinic is not a 7/24 emergency department. Marked swelling or deformity after a fall, an open wound, a cold, blue or numb hand, or deterioration in the child's general condition requires calling 112 or attending the nearest hospital emergency department without delay.

Diagnosis is largely based on history and examination. The mechanism, usually pulling the arm, the child's age, arm position and absence of swelling or bruising form the typical pattern. The elbow, forearm, wrist and collarbone are examined together because children cannot always locate pain precisely and its source may be nearby.

X-rays are usually unnecessary when the history and examination are typical. They are requested if there has been a fall or blow, if elbow swelling or tenderness is prominent, or if the child has not started using the arm after the procedure. Imaging aims to exclude the fractures around the elbow that are common in children; for general management of childhood fractures, see fracture treatment.

Treatment restores the radial head to its normal position beneath the annular ligament (reduction). A doctor performs this procedure in seconds, usually without medicine or anaesthesia. The child may cry briefly during the procedure, with relief expected soon afterwards.

After a successful procedure, children usually start using the arm spontaneously within a short time, although this can sometimes take several tens of minutes. They are therefore observed afterwards. If arm use does not resume, the procedure may be repeated or X-rays requested to investigate another injury.

A cast, splint or prolonged sling is unnecessary in most cases. The ligament heals quickly and the child resumes normal activity. A brief sling and review may be arranged if needed.

Recurrence is possible after one episode because underlying laxity persists until growth corrects it. Simple habits protecting the child's arm are recommended in recurrent cases:

• Do not lift or swing a child by the hands
• Support the child under the armpits or around the trunk when lifting
• Avoid sudden pulls while holding the child's hand; hold gently by the hand rather than the wrist
• When dressing, open the garment to fit over the arm without forcing it
• Inform carers, siblings and grandparents about the same precautions