Pulled (Nursemaid’s) Elbow (Radial‑head Subluxation) Introduction
Pulled elbow (nursemaid’s elbow) is a common paediatric presentation caused by subluxation of the radial head with interposition of the annular ligament between the radial head and the capitellum. It typically causes immediate pain and refusal to use the affected arm.
Diagnosis is clinical and prompt closed reduction usually produces rapid pain relief and return of function. Recognition and early, appropriate management in the ED avoids unnecessary imaging and delay.
Epidemiology
- Peak incidence is in toddlers, most commonly 1-4 years of age, with a mean of approximately 28 months.
- It is rare after 5 years of age because the annular ligament becomes thicker and less mobile.
- There is a slight female predominance. (RCEM Learning)
Mechanism and pathophysiology
- The classic mechanism is sudden longitudinal traction on an outstretched, pronated hand or forearm (for example, pulling a child by the hand). Falls may also precipitate it.
- Pathology: the annular ligament slips over or becomes trapped under the radial head, producing a partial radiocapitellar subluxation.
- In older children, a stronger ligament makes this injury less likely.
Clinical features
- Sudden onset arm or elbow pain after a traction event; the child typically holds the arm slightly flexed at the elbow with the forearm pronated and close to the body.