Paediatric Elbow Injuries

Each injury has a recognisable picture. A supracondylar fracture typically affects a younger child, with a peak age of five to seven, who has fallen onto an outstretched hand and presents with elbow pain, swelling and reluctance to move the arm. Marked swelling, deformity or anterior skin puckering suggests significant displacement. The neurovascular examination is the clinical priority and must be documented: record the radial pulse, hand colour, temperature and digital capillary refill time, and test anterior interosseous nerve function (flexion of the thumb interphalangeal and index distal interphalangeal joints, the 'OK' sign) along with median, ulnar and radial nerve function. Repeat and document this after splinting, after any reduction, and at handover. Distinguish a pink, well-perfused but pulseless hand from a white, poorly perfused pulseless hand, because the latter is a vascular emergency.

A medial epicondyle avulsion usually affects an adolescent, around nine to fifteen years, after a fall, a dislocation, or during throwing, with medial elbow pain, local swelling and tenderness over the medial epicondyle, and sometimes valgus instability. Ulnar nerve assessment is essential, testing sensation in the little and ring fingers and the intrinsic hand muscles. A pulled elbow presents as a distressed toddler who suddenly stops using the arm, classically after being pulled or swung by the hand, though a witnessed pull is not always present. The child holds the arm slightly flexed and pronated, with no swelling, bruising, warmth or deformity, and resists supination; tenderness is poorly localised. The combination of a typical picture with an absence of swelling or focal bony tenderness is reassuring.

Plain radiographs, an anteroposterior and a true lateral of the elbow, are first-line, and a true lateral is essential for interpreting the alignment lines and the fat pad signs.

Several assessments structure interpretation. The anterior humeral line, drawn down the anterior cortex of the humerus on the lateral view, should pass through the middle third of the capitellum in children aged five and over; posterior displacement of the capitellum relative to this line indicates an extension-type supracondylar fracture. In younger children the line may normally fall through the anterior third, but it should still intersect the capitellum. The radiocapitellar line, drawn through the radial neck, should bisect the capitellum on every view, and failure to do so suggests radial head subluxation or dislocation. Fat pad signs matter: an elevated anterior fat pad (the 'sail sign') or any visible posterior fat pad indicates a joint effusion or haemarthrosis, and a visible posterior fat pad is always abnormal and implies an occult fracture until proven otherwise. Finally, use CRITOE to confirm that the ossification centres present are appropriate for age and that the medial epicondyle is accounted for.

Pulled elbow does not usually require imaging when the presentation is classic; reserve radiographs for atypical features such as swelling, deformity, the wrong age or mechanism, or a failed reduction. Computed tomography or magnetic resonance imaging is occasionally used in secondary care for surgical planning or to clarify an intra-articular fragment.

Management depends on the specific injury and the degree of displacement, and centres on prompt recognition and the correct referral.

For supracondylar fractures, undisplaced injuries (Gartland type I) are managed non-operatively with an above-elbow backslab or cast at around 90 degrees of flexion and orthopaedic follow-up. Displaced fractures (Gartland types II and III) need urgent orthopaedic referral and are usually treated on the day of injury, typically with closed reduction and percutaneous Kirschner-wire (K-wire) fixation. A white, poorly perfused pulseless hand is an emergency. A pink, well-perfused but pulseless hand still needs urgent assessment and usually same-day reduction and stabilisation, because perfusion commonly returns once the fracture is reduced; an otherwise non-ischaemic limb does not require artery exploration simply because the pulse is absent, but a hand that remains ischaemic after reduction does require surgical exploration. In the meantime, provide analgesia, splint in a position of comfort without forcing the elbow, and keep the child fasted pending assessment.

For medial epicondyle avulsions, recent evidence has shifted UK practice. The SCIENCE trial (2026), a large multicentre randomised trial in children aged seven to fifteen, found no clinically meaningful benefit from surgical fixation over non-surgical care for isolated displaced fractures, with more complications after surgery, and concluded that non-surgical care should be the default regardless of whether the elbow was dislocated at presentation. Non-surgical care, with a short period of immobilisation followed by graded mobilisation, therefore starts as the default for an isolated displaced fracture. Urgent orthopaedic referral remains necessary for an incarcerated intra-articular fragment, an open fracture, ulnar nerve palsy or entrapment, gross instability, a complex intra-articular injury, or an associated dislocation needing reduction. High-demand throwing or gymnastics participation should prompt specialist discussion rather than serve as a standalone reason to operate.

For a pulled elbow, give simple analgesia and reduce, with hyperpronation often preferred as the first attempt because it tends to be more successful and less painful than supination-flexion. Review after about fifteen minutes; if the child is still not using the arm, repeat using the alternative technique. Request radiographs if the arm is still not used after a repeat attempt, or if the presentation is atypical. No immobilisation is needed after a successful reduction.

Children remodel well, but the elbow is prone to stiffness, so the guiding principle is protected early movement rather than prolonged rigid immobilisation once it is safe to mobilise.

After cast or wire treatment for a supracondylar fracture, gentle active range of movement is encouraged once immobilisation ends. Passive forced stretching should be avoided, as it increases the risk of myositis ossificans, and most children regain function over weeks to a few months. After a medial epicondyle injury, rehabilitation progresses from active mobilisation to strengthening, with particular attention to the forearm flexor-pronator group and a gradual reintroduction of valgus load; throwing athletes need a structured, staged throwing programme with attention to technique and sensible limits on throwing volume before full return. A pulled elbow needs no formal rehabilitation, but carers should be advised to avoid pulling or swinging the child by the hands or wrists, as recurrence is common until around five years of age.

Return to sport is graded and guided by pain-free movement and restored strength, and, for fractures, by radiographic and clinical healing confirmed by the treating team.

• •CRITOE ossification sequence: the standard framework for interpreting the paediatric elbow and for avoiding a missed medial epicondyle injury.
• •Gartland classification: grades extension-type supracondylar fractures and guides operative decision-making.
• •The SCIENCE trial (2026): a multicentre randomised trial supporting non-surgical care as the default for isolated displaced medial epicondyle fractures in children, regardless of dislocation status.
• •British Orthopaedic Association Standards for Trauma (BOAST) on supracondylar fractures of the humerus in children: the UK reference for assessment, neurovascular documentation and timing of treatment.
• •Royal College of Emergency Medicine (RCEM) guidance and National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries on the injured or limping child support assessment and referral, and NICE guidance on non-complex fracture assessment and management informs fracture care in children and young people.

• •CRITOE order is Capitellum, Radial head, Internal (medial) epicondyle, Trochlea, Olecranon, External (lateral) epicondyle, and the medial epicondyle always ossifies before the trochlea.
• •Supracondylar fracture is the commonest paediatric elbow fracture; the anterior interosseous nerve is the most commonly injured nerve, and a white pulseless hand is a surgical emergency.
• •A visible posterior fat pad on a true lateral means an occult fracture until proven otherwise, and the anterior humeral line should cross the middle third of the capitellum in children aged five and over.
• •A 'trochlear' density with an absent medial epicondyle suggests an incarcerated intra-articular fragment.
• •For isolated displaced medial epicondyle fractures, non-surgical care is now the default; refer urgently if the fragment is incarcerated, the ulnar nerve is involved, or the elbow is unstable.
• •Pulled elbow affects children aged one to four; reduce by hyperpronation or supination-flexion, with no x-ray needed if the picture is classic.