Any person, 1 year to 5 years, presenting with a suspected pulled elbow. This may include a history of a pull to the arm, excluding children with an obvious deformity, swelling, bruising or injury not isolated to the elbow.
If features are not consistent with a pulled elbow, switch to isolated limb injury protocol.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Mechanism of injury
- Pain assessment
- Pre-hospital treatment, including other reduction attempts
- Past admissions
- Medical and surgical history, including previously pulled elbow
- Current medications
- Known allergies
- Immunisation status
- Current weight
Signs and symptoms
- Not using the affected limb
- Pronated forearm with extension at the elbow
- Protective of the affected limb
- Mild elbow tenderness
- Distressed with elbow movement
- Referred wrist pain
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Delayed presentation
- Signs of non-accidental injury:
- inconsistency in history
- mechanism of injury not consistent with developmental age
Clinical
- Signs or symptoms not consistent with a pulled elbow:
- bony tenderness
- red, hot or swollen elbow
- deformity to limb
- neurovascular compromise
- severe pain at rest
Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Position
| Assessment | Intervention |
|---|---|
General appearance/first impressions | Position of comfort |
Airway
| Assessment | Intervention |
|---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
| Assessment | Intervention |
|---|---|
Respiratory rate and work of breathing | Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93% |
Circulation
| Assessment | Intervention |
|---|---|
Perfusion (capillary refill, skin warmth and colour) Heart rate | Assess circulation |
Disability
| Assessment | Intervention |
|---|---|
| AVPU | If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength |
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment as clinically indicated |
| Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
| Assessment | Intervention |
|---|---|
| Temperature | Measure temperature |
Head-to-toe inspection, including posterior surfaces | Check and document any abnormalities |
Fluids
| Assessment | Intervention |
|---|---|
Hydration status | Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses |
Glucose
| Assessment | Intervention |
|---|---|
|
BGL |
Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):
If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:
|
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Consider musculoskeletal focused assessment.
Assessment of upper limb
- Pulled elbow will generally present with arm in extension and forearm pronated.
- The patient may hold the wrist of the affected arm.
- Consider alternative diagnosis if bruising, swelling or deformity of the wrist and/or elbow.
- Do not move the elbow during examination.
- Perform neurovascular examination of the affected arm.
- Palpate the limb from clavicle to fingertips. Tenderness is usually absent.
- Resistance and pain will be observed with supination of the forearm.
- Pain in the wrist and forearm may occur. This should prompt a thorough examination to exclude a fracture.
- If features are not consistent with a pulled elbow, switch to isolated limb injury protocol.
Do not reduce an elbow if any of the following signs are present:
- Swelling or deformity in the limb
- Tenderness separate from the elbow, or excessive elbow tenderness
- Neurovascular compromise
- Signs of joint infection, e.g. red, hot or swollen joint.
Precautions and notes
- Pulled elbow is most common in children 1–4 years.
- Encourage the child to use their arm and resume normal activities post reduction.
- Once a pulled elbow has occurred, there is a high likelihood of reoccurrence. To prevent this injury, encourage parent or carer to lift the child up under their armpits instead of forearms or wrists.
Interventions and diagnostics
Specific treatment
Nurses who have completed the required education and training may make one attempt to reduce elbow using either of the following techniques:
- hyper pronation/flexion manoeuvre
- or supination/flexion manoeuvre
If the patient is unable to use the arm post reduction attempt, await medical or nurse practitioner or physiotherapist review.
Analgesia
If pain score 1–6 (mild–moderate):
Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
If severe pain present, give analgesia and escalate as per local CERS protocol.
Consider non-pharmacological pain relief (appendix).
Radiology
Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.
Pathology
Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.
Medications
The patient’s weight is mandatory for calculating fluid and medication doses.
The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
| Drug | Dose | Route | Frequency |
|---|---|---|---|
Glucose 40% gel | 4 weeks–1 year: 1–5 years: 5 g 6–11 years: 10 g 12 years and over : 15 g | Buccal | Repeat after 15 minutes if required |
Ibuprofen H, R | 3 months and over: Maximum dose 400 mg | Oral | Pain score 1–10 Once only |
0.25–15 L/min, device dependent | Inhalation | Continuous | |
15 mg/kg Maximum dose 1000 mg | Oral | Pain score 1–10 Once only |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Bexkens R, Washburn FJ, Eygendaal D, et al. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis. The American Journal of Emergency Medicine. 2017;35(1):159-63.
- Krul M, van der Wouden JC, Kruithof EJ, et al. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews. 2017 Jul 28;7(7):1-39. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28753234 DOI: 10.1002/14651858.CD007759.pub4
- Australian Medicines Handbook. Adelaide: AMH; c2023 [cited 28 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- Australian Medicines Handbook Children's Dosing Companion. Adelaide: AMH; c2023 [cited 03 May 2023]. Available from: https://childrens.amh.net.au.acs.hcn.com.au/
- The Royal Children's Hospital Melbourne. Clinical practice guidelines: Pulled elbow. Melbourne: Victoria Health; 2020 [cited 28 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Pulled_elbow/
- The Royal Children's Hospital Melbourne. Sucrose (oral) for procedural pain management in infants. Melbourne: Victoria Health; 2021 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Sucrose_oral_for_procedural_pain_management_in_infants/#
- The Sydney Children's Hospital Network. Pulled Elbow Management in the Emergency Department: Practical Guideline. Sydney: NSW Health; 2019 [cited 28 Feb 2023]. Available from: https://www.schn.health.nsw.gov.au/_policies/pdf/2011-0014.pdf
- The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
- Yamanaka S, Goldman RD. Pulled elbow in children. Can Fam Physician. 2018 Jun;64(6):439-41.
| Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
| Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
| Currency | Due for review: Jan 2026. Based on a regular review cycle. |
| Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/pulled-elbow