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Approach to Pediatric Patients With Elbow Injuries in the Emergency Department
What ED Clinicians Need to Know
Pediatric elbow injuries account for approximately 7% of musculoskeletal-related complaints in children presenting to the ED. The combination of skeletal immaturity and evolving ossification centers can make these injuries deceptively difficult to interpret. Fracture miss rates on ED radiographic interpretation have been reported to be as high as 50%, making ED management and critical decision-making especially important when findings are subtle or pediatric orthopedic support is not readily available.
Elbow injuries range from acute falls, fractures, subluxations, and dislocations to subacute overuse injuries associated with expanding participation in organized youth sports. This issue highlights common pitfalls in trauma assessment, neurovascular evaluation, pediatric elbow x-ray interpretation, and recognition of normal developmental anatomy, and also reviews the emerging role of point-of-care ultrasound and the need to identify patients who may require pediatric orthopedic expertise.
Why This Topic Matters in the ED
- Pediatric elbow injuries are common, but developmental anatomy can make subtle fractures and normal variants difficult to distinguish on x-ray.
- Some higher-risk injuries can involve nerve or vascular compromise, and early recognition affects urgency and downstream care.
- Many EDs have limited access to pediatric orthopedic specialists, leaving emergency clinicians to make key decisions about stabilization, consultation, and transfer.
- Rising youth sports participation is resulting in an increase in subacute overuse presentations, and point-of-care ultrasound is emerging as a useful adjunct in equivocal cases.
Clinical Content at a Glance
Clinical Q&A
- What injuries commonly cause pediatric elbow pain in the ED?
- This issue reviews common fractures, radial head subluxation, elbow dislocations, and sports-related overuse conditions. Age, mechanism, and skeletal maturity help frame the likely injury pattern.
- Why can pediatric elbow imaging be difficult to interpret?
- Normal ossification centers and developmental anatomy can mimic injury, and some fractures may be subtle on initial radiographs. Familiarity with normal alignment and age-related anatomy supports more confident interpretation.
- What elements of the initial evaluation are most important?
- This issue emphasizes obtaining details regarding the mechanism of injury, a focused musculoskeletal examination, assessment for associated trauma, and careful neurovascular evaluation. Findings from the initial evaluation help determine the appropriate level of imaging and specialty involvement.
- How does management vary across pediatric elbow injuries?
- Management ranges from conservative care and outpatient follow-up to more urgent orthopedic involvement for displaced, unstable, open, or neurovascularly concerning injuries. This issue organizes these decisions by injury pattern and severity.
- What is the emerging role of point-of-care ultrasound?
- POCUS is reviewed as a fast, radiation-free adjunct that may help identify effusion, occult fracture clues, and selected subluxation findings. It is particularly relevant when radiographs are equivocal or rapid bedside assessment is useful.
Case Snapshots
CASE 1 — Progressive Elbow Pain in a Young Baseball Player: A 9-year-old right-handed baseball player develops worsening right elbow pain over a month, first after games and later even separate from activity, with reduced throwing velocity. The case illustrates a sports-related overuse presentation ultimately attributed to medial epicondyle apophysitis (little leaguer’s elbow) and the importance of recognizing subacute injury in the growing athlete.
CASE 2 — Elbow Deformity After a Fall: A 6-year-old girl develops marked left elbow pain, swelling, and deformity after falling from a couch onto an outstretched hand. Imaging reveals a Type III supracondylar humerus fracture, highlighting the need to assess neurovascular status and recognize injuries that require urgent orthopedic involvement.
CASE 3 — Refusal to Use the Arm After Play: A 2-year-old boy stops moving his left arm after playing with an older sibling, with no witnessed fall, deformity, bruising, or swelling. The case highlights how age, mechanism, and examination findings guide the distinction between a clinically apparent radial head subluxation and an injury that warrants imaging before attempted reduction.
Clinical Tools
- Fracture classification tools for supracondylar, lateral condyle, medial epicondyle, proximal radius, physeal, and Monteggia injuries
- Differential diagnosis summary covering fractures, subluxation and dislocation, overuse injuries, and nontraumatic causes of pediatric elbow pain
- Hand-movement guide for assessing median, radial, ulnar, and anterior interosseous nerve function
- Reference guide to the expected appearance of pediatric elbow ossification centers across development
- ED management summary for supracondylar fractures based on injury severity and neurovascular status
- Radiographic illustrations of common pediatric elbow fracture and dislocation patterns and developmental anatomy
- X-ray interpretation tools highlighting key alignment landmarks, ossification centers, joint effusion, and occult fracture findings
- Illustrated reduction techniques for nursemaid’s elbow and elbow dislocations
- Point-of-care ultrasound examples showing the posterior elbow recess, effusion-related findings, and nursemaid’s elbow
- Clinical pathways for the management of pediatric elbow injuries, including fractures and dislocations, in the ED
Risk Management Pitfalls
- Treating an elbow injury as isolated trauma and overlooking associated injuries
- Managing an uncertain fracture as an outpatient without obtaining orthopedic input
- Missing an occult fracture or joint effusion on a pediatric elbow x-ray
- Leaving a prehospital or transfer splint in place and missing an open injury or neurovascular compromise
- Assuming nursemaid’s elbow when the mechanism or examination may indicate a fracture
Key References
Following are the most informative references cited in this paper, as determined by the authors.
9. * Sayal A. How to avoid missing a pediatric elbow fracture. ACEP Now. Updated September 2, 2020. Accessed September 1, 2026. (Review)
10. * Potocki R, Canares T. Elbow injuries in children. Pediatr Rev. 2022;43(4):236-238. (Review) DOI: 10.1542/pir.2021-004986
11. * Khan S, Novl B, Navarro YJS, et al. How to approach the pediatric elbow. EM Resident. Updated April 8, 2021. Accessed September 1, 2026. (Review)
17. * Hill C, Cooke S. Common paediatric elbow injuries. Open Orthop J. 2017;11:1380-1393. (Review) DOI: 10.2174/1874325001711011380
23. * Bašković M, Pesorda D, Zaninovic L, et al. Management of pediatric elbow fractures and dislocations. Children (Basel). 2024;11(8):906. (Review) DOI: 10.3390/children11080906
27. * Lewallen L, Elliott M, McIntosh A, et al. Pediatric elbow dislocations and associated fractures. Children (Basel). 2023;10(6):993. (Retrospective review; 117 patients) DOI: 10.3390/children10060993
CME Information
- 4 CME credits (available for subscribers)
- Includes Trauma + Risk Management
- View complete CME Information here
