History:

• Age: usually 1 to 4 years old
• In 50%: no history of a "pull" on the arm

Examination:

• not using the affected limb
• elbow in extension and the forearm in pronation
• distressed only on elbow movement
• no swelling, deformity or bruising of the elbow or wrist
• on palpation tenderness is usually absent (remember the clavicle)
• marked resistance and pain with supination of the forearm.

Manipulation during triage or xray may reduce the subluxation.

Differential diagnosis:

See  upper limb non-use guideline

Diagnosis

• Clinically established with a classic history and examination.
• Plain radiographs are indicated when a differential diagnosis is suspected:
  • significant tenderness, swelling, bruising or deformity

  • reduction fails

Treatment

• Perform a reduction manoeuvre (see below)
• expect distress and pain
• a click may be felt over the radial head
• review after ten minutes
• if reduction fails, consult with senior medical staff

Reduction manoeuvres

Either of the following methods may be effective

pronation/ flexion manoeuvre

sit the child on the parent's lap

	apply pressure over the radial head
	fully pronate forearm and then flex the elbow

supination/flexion manoeuvre

sit the child on the parent's lap

	apply pressure over the radial head
	supinate the forearm
	flex the elbow