There's a recognisable presentation parents bring to A&E with a toddler: a 2-year-old, dressed in coat and wellies, sitting on a parent's hip with one arm hanging loose against the body. They use the other arm to point. They cry the moment anyone tries to move the held arm. There's no bruise, no swelling, nothing visibly wrong. And usually a recent moment — a tug at a kerb, being swung in the park, an arm grabbed mid-stumble — that the parent now feels guilty about.
This is pulled elbow. It is not a fracture. It is not a dislocation. It is a small mechanical puzzle that a clinician can solve in about ten seconds with no equipment, and the child walks out using both arms again before the parent has finished signing the discharge paperwork.
For tracking injuries and patterns of recurrence, the Healthbooq app is useful — pulled elbow does come back in some children, and a record helps if you start to see a pattern.
The Anatomy in One Paragraph
In a child under about five, the radial head (the top of the forearm bone that joins the elbow) is small, smooth, and almost the same diameter as its neck. The annular ligament that wraps around it is loose. Pull on the forearm and the radial head slips downward, and as it does, a flap of the annular ligament gets caught and folds into the joint space. That trapped ligament is what hurts and what stops the child rotating their forearm. Nothing is broken, nothing is torn, nothing is dislocated in the strict sense. By age 5–6 the radial head has grown and the ligament has tightened, which is why pulled elbow is rare beyond that age.
How It Happens
The classic story, in roughly the order it shows up in A&E records:
- Lifting the child by the hand or wrist to clear a kerb, stairs, or puddle
- Swinging the child by the hands ("one, two, three, weeeee!")
- Pulling the child up sharply to stop a fall, with the parent holding one hand
- Tugging the arm to dress or undress (a sleeve catching on a wrist)
- A toddler self-injuring — rolling in their cot, falling onto an outstretched arm, hooking the arm under furniture
- Sibling tug-of-war with a toy
In a meaningful minority — around 1 in 4 cases — there's no clear mechanism. A toddler simply stops using the arm and the parent has no idea why. That's still consistent with pulled elbow if the rest of the picture fits.
The reassuring framing for the guilty parent: this happens because of normal toddler anatomy and ordinary parenting moments. It is not a sign of rough handling. The radiology textbooks have called it "nursemaid's elbow" since the 19th century precisely because it is the kind of thing that happens routinely while looking after a child.
What It Looks Like
A child with pulled elbow holds the affected arm:
- Pressed slightly against the body
- Elbow about 15–20° bent
- Forearm turned palm-down (pronated)
- Limp — not protected with the other hand, just held still
They will use the other arm normally. They will reach for a biscuit with the good hand. They are usually not crying continuously — they're cross or quiet, and they cry when someone tries to move the held arm.
What you should not see:
- Visible swelling or bruising
- Obvious deformity
- Tenderness over a specific bone (the wrist, the upper arm, the collarbone)
- Refusal to bear weight on a leg, or any other unrelated finding
If any of those are present, the diagnosis isn't pulled elbow and an X-ray is needed.
Why an X-ray Usually Isn't
In a textbook presentation — toddler, classic mechanism, arm held in the typical position, no swelling, no point tenderness on bone — X-ray adds no useful information. It will be normal in a true pulled elbow because nothing is broken or dislocated, and the radiation isn't trivial in a small child.
X-ray is indicated when:
- The mechanism was a fall from height, a direct blow, or something else that could fracture
- There's swelling, bruising, or visible deformity
- Bony tenderness over the wrist, distal forearm, or supracondylar region (a supracondylar fracture is the main "don't miss" — it can mimic pulled elbow but typically has more pain and swelling)
- Reduction has been attempted twice without restoring use of the arm
- The child is over 5 (pulled elbow is rare and other diagnoses become more likely)
In UK practice, NICE Clinical Knowledge Summaries and the College of Emergency Medicine both support clinical diagnosis without imaging in a typical case.
The Reduction
Two manoeuvres are commonly used. Both work; one has a slight edge.
Hyperpronation. The clinician supports the elbow with one hand, the thumb resting lightly over the radial head, and uses the other hand to firmly rotate the child's forearm palm-down (pronation) past its usual range. A small "click" is often felt under the thumb. The whole movement takes about a second.
Supination-flexion. Same elbow grip, but this time the forearm is rotated palm-up (supination) and then the elbow is bent fully. The click is felt as the elbow comes up.
A 2017 meta-analysis by Bexkens et al. in Annals of Emergency Medicine (nine trials, around 800 children) found hyperpronation succeeded on the first attempt about 95 per cent of the time versus 77 per cent for supination-flexion, with similar pain scores. Most UK and US emergency departments now teach hyperpronation as the first choice. The follow-up for failed first attempt is to try the other manoeuvre — combined success rate is well over 95 per cent.
You will sometimes feel the click; sometimes you won't. The reliable end-point is the child using the arm again, not the click itself. After a successful reduction, expect:
- A few minutes of upset (the manoeuvre is briefly uncomfortable)
- Slow, exploratory use of the arm — reaching for a sticker, a biscuit, a phone — within 5–15 minutes
- Full normal use, with no protective posturing, by 30 minutes
If the child still won't use the arm at 30 minutes despite a clear click, options are: a second attempt, a different manoeuvre, or X-ray to rule out an unsuspected fracture.
Should parents do this at home? Generally no. The manoeuvre is straightforward when you've been shown it, but the diagnostic part is harder than it looks. The "doesn't use the arm after a fall" picture overlaps with supracondylar fracture, clavicle fracture, monoarticular sepsis, and other diagnoses you don't want to miss. For families with a child who's had recurrent pulled elbow and a clear pattern, some A&E departments will teach the manoeuvre to parents — that's worth asking about, but it's a conversation with your usual ED, not a YouTube tutorial.
After the Reduction
Nothing. No splint, no sling, no follow-up. The child resumes normal play, and the parents stop worrying.
There's no benefit to "resting" the arm — once the radial head is back where it belongs, the joint is fully functional. Trying to immobilise the arm in a 2-year-old is also more or less impossible.
A useful safety-net to give parents on discharge: if the child develops new swelling or refuses to use the arm again over the next 24 hours, come back. The vast majority don't.
Recurrence and What to Do About It
Around 20–30 per cent of children with one episode of pulled elbow will have another, usually within the first year afterward. Risk goes up with younger age (closer to 1–2 than to 4–5) and with the child's ligamentous laxity.
Practical advice for parents:
- Lift under the armpits, not by the hands or wrists. This is the single highest-yield change.
- Don't swing the child by their hands. The "one-two-three-up" game is the classic offender. Swinging by the trunk (around the waist) is fine.
- Don't pull a falling child up by the wrist — better to let them sit down on their bottom than to grab the arm.
- Be careful with sleeves and coats — wrestle the sleeve, not the wrist.
- Tell other carers — grandparents, childminders, nursery staff. The injury often happens with adults who don't know about it, and the technique change matters.
Children genuinely do grow out of this — once the radial head matures around age 5, the mechanism stops working.
Key Takeaways
Pulled elbow (nursemaid's elbow, radial head subluxation) is one of the most common toddler arm injuries — peaks at 2–3 years and is genuinely rare after 5. The mechanism is almost always a longitudinal pull: swinging by the hands, yanking up to stop a fall, lifting onto a kerb. The child stops using the arm, holds it slightly bent and turned in, but there's no bruising or swelling. Reduction by an A&E clinician (hyperpronation has the edge over supination-flexion) takes seconds and the arm is back to normal within 15 minutes. No X-ray, splint, or follow-up is needed in classic cases. Recurrence is around 20–30 per cent — lift under the armpits, not by the wrists.
