Is hyperpronation better than supination to reduce radial head subluxation?
Date First Published:
February 18, 2015
Last Updated:
April 9, 2015
Report by:
Marianne Gauthier, PGY 3 Emergency Medicine (Universite Laval)
Search checked by:
Jean-Francois Shields, Universite Laval
Three-Part Question:
In [children presenting with radial head subluxation], is [hyperpronation technique superior than supination-flexion technique] at [both increasing initial success at reduction while also minimizing pain]?
Clinical Scenario:
A healthy 3 year-old girl is brought into Emergency Department by her mother. She lifted her up on the couch by pulling on her left hand from this moment her daughter didn’t use her left arm. This little girl has a clear history of a ’’pulled elbow’’. You wonder whether supination-flexion or hyperpronation is the best technique for this reduction.
Search Strategy:
Search conducted on October 16th, 2014
A.tThe website clinicaltrials.gov was searched for an ongoing trial on the topic.
1)tOne study not active since March 2012
B.tMEDLINE (PubMed)
1)t((((elbow joint[MeSH Terms]) AND dislocation[MeSH Terms])) OR pulled elbow) OR radial head subluxation = 1622 articles
2)t(((supination[MeSH Terms]) AND pronation[MeSH Terms]) OR (supination AND pronation) = 2200
3)t1 AND 2 = 104 articles
4)tFilters : Infant: birth-23 months; Infant: 1-23 months; Preschool Child: 2-5 years; Child: 6-12 year = 43 articles
5)tFilters : Clinical Trial; Randomized Controlled Trial; Meta-Analysis; Systematic Reviews = 8 articles
6)tAfter abstract review = 7 articles
C.tEMBASE
1)t'elbow dislocation'/exp OR 'elbow dislocation' OR 'pulled elbow' OR 'radial head subluxation' = 1377 articles
2)tsupination AND pronation = 2140 articles
3)t1 AND 2 = 76 articles
7)tFilters: Infant: 1-12 months; Child : 1-12 years ; Preschool Child: 1-6 years; School child: 7-12 year = 22 articles
4)tFilters: cochrane review ; systematic review ; controlled clinical trial ; randomized controlled trial ; meta analysis = 5 articles
5)tAfter abstract review = 5 articles relevant already found with MedLine
A.tThe website clinicaltrials.gov was searched for an ongoing trial on the topic.
1)tOne study not active since March 2012
B.tMEDLINE (PubMed)
1)t((((elbow joint[MeSH Terms]) AND dislocation[MeSH Terms])) OR pulled elbow) OR radial head subluxation = 1622 articles
2)t(((supination[MeSH Terms]) AND pronation[MeSH Terms]) OR (supination AND pronation) = 2200
3)t1 AND 2 = 104 articles
4)tFilters : Infant: birth-23 months; Infant: 1-23 months; Preschool Child: 2-5 years; Child: 6-12 year = 43 articles
5)tFilters : Clinical Trial; Randomized Controlled Trial; Meta-Analysis; Systematic Reviews = 8 articles
6)tAfter abstract review = 7 articles
C.tEMBASE
1)t'elbow dislocation'/exp OR 'elbow dislocation' OR 'pulled elbow' OR 'radial head subluxation' = 1377 articles
2)tsupination AND pronation = 2140 articles
3)t1 AND 2 = 76 articles
7)tFilters: Infant: 1-12 months; Child : 1-12 years ; Preschool Child: 1-6 years; School child: 7-12 year = 22 articles
4)tFilters: cochrane review ; systematic review ; controlled clinical trial ; randomized controlled trial ; meta analysis = 5 articles
5)tAfter abstract review = 5 articles relevant already found with MedLine
Outcome:
SEARCH OUTCOME:
3 relevant articles (1 meta-analysis was found from 2012, since 2012 2 additional RCT were found)
3 relevant articles (1 meta-analysis was found from 2012, since 2012 2 additional RCT were found)
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Manipulative interventions for reducing pulled elbow in young children. Krul M, van der Wouden JC, van Suijlekom-Smit et al. 2012 Netherlands | 4 RCT met the inclusion criteria: Bek 2009 Green 2006 Macias 1998 MacDonald 1998 Total of 379 patients, 356 were pooled for the primary outcome. |
Meta-analysis | pain and distress during intervention | Two trials reported that pronation might be less painful | High risk of bias (lack of assessor blinding, lack of allocation concealment in one trial) Insufficient data on pain |
| Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation. Guzel M, Salt O, Demir MT et al. 2014 Turkey | 78 children with radial head subluxation | RCT | Success of reduction | HP 97,5 % (38/40) p 0,04 and SF 84,2 % (32/38) p <0,05 | Not blinded |
| Success at first attempt: | HP 92 % (36/40) and SP 78 % (25/38) | ||||
| Pain related to the technique | No significant difference | ||||
| Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid's elbow cases. Gunaydin YK, Katirci Y, Duymaz H et al. 2013 Turkey | 150 children with radial head subluxation | RCT | Successful reduction | HP 94,8 % (91/93) and SF 70,2 % (59/84) p <0,001 | Not blinded |
| Success at first attempt | HP 95,6 % (65/68) and SP 68,3 % (56/82) p <0,001 | ||||
| Pain related to the technique | No significant difference |
Author Commentary:
The evidence appears to consistently suggest that hyperpronation is more effective than supination-flexion to reduce radial head subluxation. The systematic review is cautious in its conclusions because of some lacks in the methodology, but it is not possible to blind this kind of treatment. The more recent RCT has a better methodology. Finally, the papers have failed to get significant data on pain during procedure.
Bottom Line:
Hyperpronation technique should be tried first to reduce a radial head subluxation, because it is more successful at the first attempt, but no significant difference in terms of pain.
References:
- Krul M, van der Wouden JC, van Suijlekom-Smit et al.. Manipulative interventions for reducing pulled elbow in young children.
- Guzel M, Salt O, Demir MT et al.. Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation.
- Gunaydin YK, Katirci Y, Duymaz H et al.. Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid's elbow cases.