Aims To establish 1) the proportion of pulled elbows with an alternative mechanism of injury to the traditional tractional force, and 2) the incidence of patients undergoing radiological imaging, including timing and indication for each investigation.

Methods A retrospective cohort study was performed using all patients presenting with a pulled elbow to the Emergency Department between 1st May 2014 to 30th April 2015. Inclusion and exclusion criteria were used to establish the final cohort of 376 patients included in this study. Demographic data was collected, as well as the mechanism of injury, and the number of previous presentations for pulled elbow. Additionally, this study identified those who underwent radiological imaging, timing of investigation and clinical reasoning for each test.

Results 61% of patients were female. The median age was 2 years old. 125 children (33%) had past medical history of pulled elbow; majority had only had one. 253 patients (67%) presented with traditional tractional mechanism. Remaining 123 patients (33%) had alternative mechanism of injury which was further subdivided: trauma (20%); unwitnessed injury (8%); no trauma (5%).

80 children (21%) underwent radiological imaging: 24% of these had traditional mechanism and 76% alternative (p < 0.05). 66 children (83%) had imaging before manipulation of which 55 had history of trauma, and 11 had an unclear mechanism. Remaining 14 children (17%) underwent imaging following manipulation.

Conclusion Notably, 33% of children diagnosed with a pulled elbow presented with an alternative mechanism of injury. This study adds to current literature by further subdividing those with an alternative mechanism into more specific subgroups – trauma, unwitnessed injury and no trauma.

This study identified that 21% of children underwent radiological imaging. The principal reason for such investigation was to exclude underlying injuries such as a fracture. Again this study adds to existing literature by exploring the clinical reasons for obtaining a radiograph in pulled elbow presentations.

Finally, 33% had past history of pulled elbow highlighting the importance of improving parental education to help reduce re-attendance.