Upper limb non-use

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  • See also

    Pulled elbow
    The acutely swollen joint
    Bone and joint infection
    Child abuse

    Key Points

    1. The most common cause is trauma eg pulled elbow
    2. Give analgesia early
    3. Fever or systemic features are red flags
    4. Consider child abuse in children with an unclear history or concerning physical and/or radiological findings


    • The most common causes for upper limb non-use in children are pulled elbow and fractures of the upper limb and clavicle
      • Toddlers may present with just upper limb non-use as trauma was unwitnessed
    • Consider serious causes such as infections or child abuse
    • Neonates and children with underlying medical conditions, such as bleeding disorders or haemoglobinopathies, should be reviewed carefully



    • History of trauma and mechanism of injury
    • History of “pull” on the arm
    • Unable to move arm without history of injury
    • Pain present or absent
    • Location of symptoms
    • Acute or sub-acute onset of symptoms
    • Duration of symptoms ≥ 7 days
    • Systemic features: fever, night sweats, malaise, rash, pallor, bruising
    • Neurological signs/symptoms: headache, seizures, paraesthesia, weakness
    • Constitutional symptoms: weight loss, lethargy, anorexia
    • History of other medical conditions eg bleeding disorders, sickle cell disease


    • General appearance of child – well/unwell, significant distress or pain
    • Fever
    • Fully expose the upper limb
    • Joint and limb assessment using the “Look, Feel, Move”, start with the unaffected side
      • Look: resting position of upper limbs, spontaneous movement, swelling, deformity, open wounds, erythema, bruising, rash
      • Feel: palpate from clavicle to fingers assessing for tenderness, temperature changes, swelling or joint effusions
      • Move:
        • active: facilitate by placing toy or parent out of reach
        • passive: assess for limitations and asymmetry
        • compare with contralateral side
    • Neurovascular assessment
    • Consider systemic examination if no history of trauma or pull

    Differential Diagnoses



    Key features


    Pulled elbow

    • 50% have no history of “pull” on the arm
    • Elbow in extension and the forearm in pronation
    • Distressed only on elbow movement, especially pronation/supination
    • Marked resistance and pain with supination of the forearm

    Upper limb fracture

    • Pain and reluctance to use affected area/loss of movement
    • Swelling, tenderness and deformity (may not always be obvious)

    Clavicle fracture

    • History of fall onto outstretched hand
    • Pain, swelling and deformity along the line of the clavicle

    Soft tissue injury

    • History of injury


    Septic arthritis

    • Systemic features: fever (acute onset)
    • Severe localised joint and/or limb pain
    • Hot, swollen, painful, immobile joint


    • Systemic features may or may not be present
    • Subacute onset of refusal to use limb
    • Limb pain may be poorly localised


    Bone/soft tissue malignancy
    Solid organ tumour

    • Fever, weight loss, lethargy, fatigue, anorexia, night sweats
    • Nocturnal pain
    • Pallor, bruising
    • Hepatosplenomegaly/abdominal mass

    Pain syndrome

    Complex regional pain syndrome

    • Limb pain: allodynia, hyperalgesia
    • Swelling and/or changes in skin colour of the affected limb
    • Dry, mottled skin
    • Hyperhidrosis
    • Consider probing for psychosocial stressor/trigger


    Brachial plexus neuropathy

    • Associated with birth trauma in neonates and clavicle and proximal humerus fractures
    • Inability to move affected arm
    • Muscle wasting
    • Altered sensation


    • Focal limb or facial weakness
    • Visual or speech disturbance
    • Limb incoordination or ataxia

    /  Immunological

    Juvenile idiopathic arthritis

    • Fever, rash
    • Oligo/polyarticular arthritis
    • Enthesitis
    • Psoriasis
    • Haematuria
    • Hepatosplenomegaly

    Reactive arthritis

    • Recent illness: pharyngitis, gastroenteritis, urethritis
    • Onset 7 to 14 days later
    • Oligo/monoarticular arthritis, normally lower limbs

    Child abuse

    • No history to account for the injury or history does not easily account for the findings
    • Mechanism incompatible with the child’s age or developmental capabilities

    Special considerations:

    • Minor trauma can result in haemarthrosis in children with an underlying bleeding disorder
    • Vaso-occlusive crisis may be the cause of upper limb non-use in children with sickle cell disease
    • Neonates may present shortly after birth with a brachial plexus injury +/- clavicle or humerus fracture following a traumatic birth


    Upper limb non-use


    • No investigations required if high suspicion of pulled elbow
    • X-ray (area of suspicion)
      • X-ray often normal in septic arthritis or early osteomyelitis
    • Bloods including FBE CRP and ESR
      • Elevated inflammatory markers suggest infective or inflammatory cause for limb non-use
      • FBE and film may reflect malignant process
    • Ultrasound may be useful to investigate for evidence of effusion
    • MRI or bone scan can be considered, in consultation with specialist team


    • Definitive management is determined by the working diagnosis
    • Simple analgesia (paracetamol +/- NSAID). Escalation of analgesia may be required but should prompt reassessment. Seek senior advice
    • Child-led restriction of activity for pulled elbows and soft tissue injuries
    • Splint/manage suspected fractures and follow up accordingly
    • Septic arthritis is an orthopaedic emergency, consult local specialist team urgently
    • More specific treatment for other diagnoses of upper limb non-use should be in consultation with local specialist teams

    Consider consultation with local paediatric team when

    • The child is systemically unwell
    • Septic arthritis is the suspected diagnosis
    • There are laboratory or radiological features consistent with malignancy
    • There are concerns of possible child abuse
    • Symptoms persist for ≥ 7days
    • Symptoms persist or progress without a clear diagnosis

    Consider transfer when

    Child requires care beyond the level of the local health service

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    • The cause of upper limb non-use has been identified and adequately managed


    • The child is using the arm more comfortably with or without analgesia AND
    • High risk diagnoses have been considered AND
    • There is an adequate follow up plan in place with clear instructions on when to seek earlier review

    Parent information

    Kids Health Info fact sheets: Fractures (broken bones)
    Kids Health Info fact sheets: Pulled elbow
    Kids Health Info fact sheets: Pain relief for children – paracetamol and ibuprofen
    Kids Health Info fact sheets: Osteomyelitis
    Kids Health Info fact sheets: Septic arthritis

    Last updated July 2023

  • Reference List

    1. Aylor, M et al. Reduction of pulled elbow. New England Journal of Medicine. 2014. 371:e32. DOI: 10.1056/NEJMvcm1211809. https://www.nejm.org/doi/pdf/10.1056%2FNEJMvcm1211809
    2. Dartnell J, et al. Instructional Review: Haematogenous acute and subacute paediatric osteomyelitis. A systematic review of the literature. Journal of Bone and Joint Surgery. Br. 2012. 94-B:584-95.
    3. Epps, R et al. Paediatric Septic arthritis. Orthopedic Clinics of North America. 2017. 48:209-216.
    4. Krul, M et al. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews. 2017. Issue 7. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007759.pub4/epdf/full (viewed 20 Sept 2022).
    5. Lipton, G et al. Immobile Arm. In: Shaw, K et al. Fleisher & Ludwig’s Textbook of Pediatric Emergency Medicine. 8th Edn. 2021. Wolters Kluwer. Philadelphia.
    6. Nannery, R et al. Approach to Joint Pain in Children. Paediatric and Child Health. 2018 Feb;28(2):43-49.
    7. Owen, A et al. Paediatric Clinical Practice Guideline on Elbow Injuries. BSUH (Brighton and Sussex University Hospitals) Paediatric Guidelines. https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2020/06/Paediatric-Guidelines-Elbow-injuries-2019-2.pdf (viewed March 2023).
    8. Schutzman, S et al. Evaluation of the immobile arm in children. UpToDate. Last updated March 2022. (viewed March 2023).
    9. Skaggs, D et al. Supracondylar fractures of the distal humerus. In Beaty JH, Kasser JR (Eds). Rockwood and Wilkins' Fractures in Children, 7th Edn. 2010. Lippincott Williams & Wilkins, Philadelphia. p.487-532.
    10. Vardiabasis, N et al. Definitive Diagnosis of Children Presenting to A Pediatric Emergency Department With Fever and Extremity Pain. Journal of Emergency Medicine. 2017. Sep;53(3):306-312.