What is the likely diagnosis and recommended management for a 3‑year‑old girl who cries with pain when lifted by placing hands under her arms?

Radial Head Subluxation (Nursemaid's Elbow)

The most likely diagnosis is radial head subluxation (nursemaid's elbow), which is the most common cause of acute upper extremity pain in children aged 1–4 years when lifted by the arms, and immediate reduction should be attempted without radiographs if clinical findings are consistent.

Clinical Presentation and Epidemiology

• Radial head subluxation accounts for 63% of all upper extremity injuries in children under 6 years, making it by far the most common diagnosis in this scenario 1
• The mean age of children with radial head subluxation is 27 months (approximately 2.3 years), which matches your patient's age of 3 years 1
• The classic mechanism is axial traction on an extended, pronated arm—exactly what occurs when lifting a child under the arms 1

Key Diagnostic Features

Clinical Findings That Support Radial Head Subluxation:

• Decreased arm movement is the hallmark finding and strongly correlates with this diagnosis 1
• Absence of swelling distinguishes it from fractures 1
• A pulling mechanism of injury (such as lifting by the arms) is highly predictive 1
• The child typically holds the affected arm in slight flexion and pronation, refusing to use it 1

Clinical Findings That Suggest Alternative Diagnoses:

• Point tenderness and swelling strongly correlate with fractures rather than subluxation 1
• If these findings are present, obtain radiographs before attempting reduction 1

Management Algorithm

Step 1: Clinical Assessment

• Examine for point tenderness, swelling, and deformity—if any are present, obtain radiographs first 1
• If the child has decreased arm movement without swelling or point tenderness, and the mechanism was traction, proceed directly to reduction 1

Step 2: Reduction Technique

• Immediate attempted reduction is appropriate without radiographs when clinical findings are consistent with radial head subluxation 1
• Two reduction techniques exist (hyperpronation or supination-flexion); both are effective 1
• The child should resume normal arm use within minutes if reduction is successful 1

Step 3: Post-Reduction Assessment

• If the child does not improve within 15–30 minutes after reduction, obtain radiographs to rule out fracture 1
• All children without fractures recovered completely within 1 week, confirming the benign nature of this condition when properly managed 1

Pain Management Considerations

• Pain assessment should begin immediately and continue throughout the evaluation, using age-appropriate tools such as the FLACC scale for this 3-year-old 2
• Analgesia should not be withheld while evaluating the injury; appropriate pain medication does not interfere with clinical assessment 2
• For a cooperative 3-year-old, nonpharmacologic methods (parental presence, distraction, comfort positioning) should be employed first 2
• If reduction is delayed or the child is in significant distress, consider oral analgesics (acetaminophen or ibuprofen) 2

Critical Pitfalls to Avoid

• Do not assume all arm injuries in toddlers are radial head subluxation—while it is the most common diagnosis, fractures account for 22% of cases in this age group 1
• Never attempt reduction if there is point tenderness, swelling, or an unclear mechanism of injury—obtain radiographs first 1
• Consider non-traumatic causes in children under 6 months old, as infection and neurologic impairment are more common than radial head subluxation in this younger age group 1
• Ensure appropriate follow-up for any child who does not have a clear diagnosis at the initial visit, as soft-tissue injuries and rare conditions (osteomyelitis, neurologic impairment) require ongoing monitoring 1

When to Obtain Radiographs

• Presence of swelling or point tenderness 1
• Mechanism of injury inconsistent with simple traction (e.g., fall, direct trauma) 1
• Age under 6 months, where non-traumatic causes are more likely 1
• Failure to improve after attempted reduction 1
• Recurrent episodes, which may warrant evaluation for ligamentous laxity or alternative diagnoses 1