See also

Fractures
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

Background

• 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

Assessment

History

• 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

Examination

• 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

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

Management

Investigations

• 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

Treatment

• 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

OR

• 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