In a 4‑year‑old girl who fell while jumping and now has a swollen right elbow with the forearm held in a partially pronated position, what are the likely injuries and how should they be managed?

Likely Diagnosis and Management of Pediatric Elbow Injury with Mid-Prone Forearm Position

This 4-year-old girl most likely has a radial head subluxation (pulled elbow/nursemaid's elbow), and immediate closed reduction should be attempted without radiographs if the mechanism and presentation are classic.

Most Likely Diagnosis

Radial head subluxation (pulled elbow) is the primary diagnosis given the age, mechanism (fall with traction force), swollen elbow, and characteristic mid-prone forearm position 1, 2. This injury occurs when axial traction is applied to an extended arm with the forearm pronated, creating a transverse tear in the annular ligament that permits subluxation of the radial head 1. The typical age range is up to 5 years, making this 4-year-old patient classic for this injury 2.

Key Clinical Features to Confirm Diagnosis:

• Refusal to use the affected arm after the injury 2
• Forearm held in pronation (mid-prone position as described) 1, 2
• No obvious deformity beyond swelling 2
• Point tenderness over the radial head 3

Immediate Management Algorithm

Step 1: Clinical Assessment Without Initial Radiographs

• Attempt closed reduction immediately if the history and physical examination are consistent with radial head subluxation 3, 2
• Radiographs are typically normal in pulled elbow and can delay treatment 2

Step 2: Reduction Technique

• Perform supination-flexion maneuver: Supinate the forearm fully while flexing the elbow 1, 3
• Alternative hyperpronation technique can be used if supination-flexion fails 3
• Success indicator: Child begins using the arm within minutes after reduction 2

Step 3: Post-Reduction Assessment

• If successful reduction (child uses arm normally within 5-15 minutes): No radiographs needed, no immobilization required 3
• If reduction fails or atypical features present: Obtain radiographs immediately 3, 2

When to Obtain Radiographs

Obtain plain radiographs (AP, lateral, and oblique views) immediately if:

• Reduction attempt fails 3, 2
• Significant swelling suggests fracture 4, 5
• Mechanism suggests high-energy trauma (fall from height) 6
• Visible deformity present 4
• Point tenderness over bony prominences other than radial head 6
• Age >5 years (less typical for pulled elbow) 2

The American College of Radiology recommends plain radiographs as first-line imaging to identify fractures, dislocations, and other bony pathology requiring urgent intervention 4, 5.

Alternative Diagnoses to Consider

Supracondylar Fracture

• Most common extraarticular fracture of the distal humerus in children 6
• Presents with significant swelling and deformity
• Requires immediate radiographs and orthopedic consultation 4, 6
• High risk of neurovascular complications 6

Lateral Condyle Fracture

• Most common incomplete intraarticular lesion in pediatric elbows 6
• Requires operative treatment in most cases 6

Elbow Dislocation

• Less common than radial head subluxation but possible with fall mechanism 3
• Presents with obvious deformity and inability to move elbow 7, 3
• Requires immediate radiographs and closed reduction under sedation 5, 3

Critical Management Pitfalls to Avoid

Do Not:

• Delay reduction while waiting for radiographs if clinical presentation is classic for pulled elbow 3, 2
• Perform forceful passive mobilization during rehabilitation, as the elbow has a natural tendency to develop myositis ossificans 7
• Immobilize unnecessarily after successful reduction of radial head subluxation—early mobilization is preferred 3
• Miss a surgical indication: If closed reduction fails, surgical reduction may be necessary (rare but documented) 1

Do:

• Obtain matched views of both elbows if radiographs are needed but positioning is difficult due to pain 2
• Perform early repeat radiography in any doubtful case, even if initial films appear normal 2
• Assess neurovascular status before and after any reduction attempt 7
• Consider operative treatment for most pediatric elbow fractures, as they typically require surgical fixation unlike adult injuries 6

Follow-Up Recommendations

• No follow-up needed if successful reduction of radial head subluxation with immediate return to normal function 3
• Orthopedic referral within 24-48 hours if any fracture identified on radiographs 6
• Immediate orthopedic consultation for elbow dislocation or displaced fractures 4, 5
• Parent education about recurrence risk (20-30% for pulled elbow) and avoidance of pulling on extended, pronated arms 3