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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. The website clinicaltrials.gov was searched for an ongoing trial on the topic.
1) One study not active since March 2012
B. MEDLINE (PubMed)
1) ((((elbow joint[MeSH Terms]) AND dislocation[MeSH Terms])) OR pulled elbow) OR radial head subluxation = 1622 articles
2) (((supination[MeSH Terms]) AND pronation[MeSH Terms]) OR (supination AND pronation) = 2200
3) 1 AND 2 = 104 articles
4) Filters : Infant: birth-23 months; Infant: 1-23 months; Preschool Child: 2-5 years; Child: 6-12 year = 43 articles
5) Filters : Clinical Trial; Randomized Controlled Trial; Meta-Analysis; Systematic Reviews = 8 articles
6) After abstract review = 7 articles

C. EMBASE
1) 'elbow dislocation'/exp OR 'elbow dislocation' OR 'pulled elbow' OR 'radial head subluxation' = 1377 articles
2) supination AND pronation = 2140 articles
3) 1 AND 2 = 76 articles
7) Filters: Infant: 1-12 months; Child : 1-12 years ; Preschool Child: 1-6 years; School child: 7-12 year = 22 articles
4) Filters: cochrane review ; systematic review ; controlled clinical trial ; randomized controlled trial ; meta analysis = 5 articles
5) After abstract review = 5 articles relevant already found with MedLine

Search Outcome

SEARCH OUTCOME:
3 relevant articles (1 meta-analysis was found from 2012, since 2012 2 additional RCT were found)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Krul M 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
Guzel M 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
Gunaydin 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

Comment(s)

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.

Editor Comment

KH

Clinical 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

1. Krul M, van der Wouden JC, van Suijlekom-Smit et al. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2012 Jan 18;1:
2. Guzel M, Salt O, Demir MT et al. Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation. Niger J Clin Pract 2014 Mar-Apr;17(2):201-4
3. 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. American Journal of Emergency Medicine 2013 Jul;31(7):1078-8.