Treatment for Recurrent Pulled Elbow (Radial Head Subluxation) in Children
For recurrent radial head subluxation in children, immediate manual reduction using the pronation technique is the treatment of choice, and parents should be educated on prevention strategies to avoid future episodes, as there is no specific prophylactic intervention that prevents recurrence. 1, 2
Acute Management of Each Episode
Reduction Technique
- Use the pronation method as first-line treatment, as it demonstrates superior effectiveness compared to supination, with significantly lower failure rates (risk ratio 0.45) and less pain during the procedure 2
- If reduction fails after 2-3 attempts with both pronation and supination techniques, obtain imaging to rule out fracture or confirm annular ligament entrapment 1
- The injury occurs when the annular ligament becomes entrapped in the radiocapitellar space after traction on the extended, pronated arm 3
Clinical Presentation to Confirm
- Child presents with sudden acute pain and refusal to use the affected arm following a pulling mechanism 4
- Most common in children aged 1-4 years, with peak incidence at 2-3 years 3, 4
- This is primarily a clinical diagnosis and does not routinely require imaging unless reduction fails or history is atypical 5
Important Caveat for Nonambulatory Infants
Always obtain radiographs in nonambulatory infants before attempting reduction, as radial head subluxation is uncommon in this age group and forearm fractures can mimic the presentation 6
- Nonambulatory infants with suspected pulled elbow require x-ray evaluation prior to reduction attempts to avoid missing fractures that may indicate abuse 6
Management of Recurrent Episodes
No Specific Prophylactic Treatment
- There is no established medical or surgical intervention to prevent recurrent radial head subluxation 1, 2
- Each recurrent episode should be treated with manual reduction using the same technique 2, 5
Parent Education is Critical
- Educate caregivers to avoid sudden pulling or jerking motions on the child's extended arm, as this is the primary mechanism of injury 3, 4
- Instruct parents on proper lifting techniques: lift children by grasping under the armpits or around the torso, never by pulling on the hands or wrists 4
- Explain that recurrence is common after the first episode, but the condition typically resolves as the child grows and the annular ligament strengthens 3, 5
When to Consider Alternative Diagnoses
- If reduction attempts fail after 2-3 attempts with both techniques, imaging is mandatory to rule out fracture 1
- Consider fracture if the mechanism is atypical (fall, direct trauma rather than pulling) 6
- In children younger than 5 years with arm trauma, always screen for child abuse as a potential etiology 7
Natural History and Prognosis
- The condition is self-limited and becomes less common as children age beyond 5-7 years, when the annular ligament becomes stronger and more firmly attached 3, 5
- Recurrence risk is highest after the first episode, but no specific intervention prevents future subluxations beyond caregiver education 2, 4