Ultrasonographic natural history of irreducible pulled elbow managed by supervised neglect

Although pediatric pulled elbow (PE) typically responds well to standard closed reduction maneuvers, occasional irreducible episodes present a clinical challenge. Currently, optimal management guidelines for these refractory cases remain unestablished, particularly regarding the necessity of immediate surgical intervention or rigid immobilizatiom. We report the outcomes of a "supervised neglect" strategy-observation without external immobilization-for irreducible PE. We retrospectively reviewed six consecutive cases of irreducible PE treated at our institution between 2020 and 2025, and the mean age was 3.4 years. All patients were diagnosed with ultrasonography after failed manual reduction attempts. Patients were managed without external immobilization and monitored using ultrasonography until reduction was confirmed and supinator muscle swelling resolved. The median time from injury to the return of spontaneous arm movement was 4 days. The median time to ultrasonographic confirmation of reduction was 10 days, and the resolution of supinator swelling was 7 days postreduction. All cases resolved spontaneously without external immobilization or surgery. Interestingly functional arm movement returned before the sonographic confirmation of reduction. Furthermore, no residual symptoms or complications were observed in any case. These findings indicate that irreducible PE can be managed successfully by using a supervised neglect strategy. Spontaneous reduction occurred in all cases within 2 weeks; therefore, external immobilization and immediate surgery may not be necessary. Ultrasonography has proven to be a valuable tool for the diagnosis and monitoring of the healing process.