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Three Part Question

In [patients with a pulled elbow] is [a pronation manoeuvre better than a supination manoeuvre] at achieving [reduction and return to function at the first attempt]?

Clinical Scenario

A 2 year old child is brought into the emergency department by her parents. They tell you that she has not used her left arm since tripping over while holding her older sisters' hand. The child is holding her left arm flexed at the elbow and semi-prone. The diagnosis is clearly a pulled elbow. You have heard various colleagues arguing vehemently for pronation and supination manoeuvres, and wonder which is actually the best method for reduction?

Search Strategy

Medline 1966-10/02 using the OVID interface.
[exp Elbow OR exp Elbow joint OR elbow.mp] AND [exp adolescence OR exp child OR exp child of impaired parents OR exp child, abandoned OR exp child, exceptional OR exp child, hospitalized OR exp child, institutionalized OR exp child, preschool OR exp child, unwanted OR exp disabled children OR exp homeless youth OR exp infant OR exp only child OR child$.mp Or exp Pediatrics OR pediatric$.mp OR paediatric$.mp] AND [exp Dislocations OR dislocation.mp OR subluxation.mp] AND [exp Manipulation, orthopedic OR manipulation.mp OR exp Pronation OR pronation.mp OR exp Supination OR supination.mp] LIMIT to human AND English.

Search Outcome

57 papers were found of which 54 were irrelevant or of insufficient quality. The remaining 3 were all randomised controlled trials. One of these was looking at supination with flexion v extension. The remaining 2 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Macias CG et al, 1998, USA	90 patients with pulled elbow over 12 months Pronation vs supination	PRCT	Success rate	95% v 77%	Not blinded
McDonald J et al, 1999, USA	148 patients with pulled elbow over 16 months Pronation vs supination	PRCT	Success rate	80% v 69% (NS)	Not blinded
			Left arm only	89% v 71%
			Pain	less with pronation (NS)

Comment(s)

The classical method for reduction of pulled elbows is supination at the wrist followed by flexion at the elbow. There has been no difference demonstrated between flexion or extension during this manoeuvre. When studying a practical procedure it is impossible to exclude all bias and this may weaken these results.

Clinical Bottom Line

Pronation with or without elbow flexion is the first line method of reduction for pulled elbows.

References

1. Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in reduction of radial head subluxations. Pediatrics 1998;102(1):10.
2. McDonald J, Whitlaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med 1999;6(7):715-8.