Pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial. Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Radial head subluxation: comparing two methods of reduction.
The purpose of this study was to compare the efficiency of the hyperpronation and supination-flexion maneuvers in the reduction of the pulled elbow.
                Sixty-six patients with pulled elbow were randomized for reduction with either hyperpronation or supination-flexion maneuvers. When the first attempt failed, a second attempt was performed with the same reduction maneuver. After failure of the second attempt the reduction maneuver was changed to the alternate method. The success rate of the reductions and the subjective rating on the difficulty of the reduction by the physician were recorded and analyzed statistically.
                Thirty-two of 34 patients (94%) in the hyperpronation group and 22 of 32 patients (69%) in the supination-flexion group were reduced at first attempt (P=0.007). Two patients in the hyperpronation group and seven patients in the supination-flexion group were reduced at the second attempt. Reduction rates were statistically similar (P=0.06). Three patients in the supination-flexion group had failed reduction at the second attempt and the reduction maneuver needed to be changed. They were successfully reduced with hyperpronation maneuver at the first attempt. Final success rate of the hyperpronation maneuver at the first attempt was statistically higher than the supination-flexion maneuver (P=0.004). Furthermore, the hyperpronation maneuver was rated significantly easier than the supination-flexion maneuver by physicians (P=0.003).
                Although final reduction rates were similar, the hyperpronation maneuver was more efficient at the first attempt, easier for physicians and less painful for the children. To determine if a difference exists in perceived pain between the forced pronation and supination-flexion methods of radial head subluxation (RHS) reduction.
                We developed a prospective randomized trial of children aged 6 months to 7 years who presented to the emergency department (ED) at Miami Children's Hospital with an immobile arm and physical findings suggestive of RHS. Children were randomized into 2 groups for RHS reduction: forced pronation and supination-flexion. Parents, physicians, and nurses were given a standard visual analog pain scale for pain assessment before, during, and at 1 minute after successful reduction.
                Seventy-five children presented to the ED with RHS; 3 children were excluded from the study because of nonadherence to the protocol and another 9 were excluded because of unsuccessful reduction during the first attempt. Of the remaining children, 32 children underwent forced pronation and 31 underwent supination-flexion. Physicians did not find a significant difference in gain scores between their perceptions of the premeasure and postmeasure of pain between those patients receiving supination-flexion and those receiving forced pronation. For nurses (P < 0.031) and parents (P < 0.043), there were statistically significant differences in gain scores. Nurses and parents perceived forced pronation as being less painful. The mean difference for parents was 1.7 cm, which exceeded the value of 1.3 cm identified as clinically significant.
                Forced pronation is perceived as less painful than the supination-flexion method by parents of children treated for RHS in our ED. To compare supination at the wrist followed by flexion at the elbow (the traditional reduction technique) to hyperpronation at the wrist in the reduction of radial head subluxations (nursemaid's elbow).
                This prospective, randomized study involved a consecutive sampling of children younger than 6 years of age who presented to one of two urban pediatric emergency departments and two suburban pediatric ambulatory care centers with a clinical diagnosis of radial head subluxation. Patients were randomized to undergo reduction by one of the two methods and were followed every 5 minutes for return of elbow function. The initial procedure was repeated if baseline functioning did not return 15 minutes after the initial reduction attempt. Failure of that technique 30 minutes after the initial reduction attempt resulted in a cross-over to the alternate method of reduction. The alternate procedure was repeated if baseline functioning did not return 15 minutes after the alternate procedure was attempted. If the patient failed both techniques, radiography of the elbow was performed.
                A total of 90 patients were enrolled in the study. Five patients were removed from further analysis secondary to a final diagnosis of fracture, 84 were reduced successfully, and 1 failed both techniques. Demographic characteristics of each group were similar. Thirty-nine of 41 patients (95%) randomized to hyper-pronation were reduced successfully on the first attempt versus 34 of 44 patients (77%) randomized to supination. Two patients in the hyperpronation group required two attempts versus 10 patients in the supination group. Hyperpronation was more successful; 40 of 41 patients (97.5%) in the hyperpronation group were reduced successfully versus 38 of 44 patients (86%) in the supination group. Of the 6 patients who crossed over from supination to hyperpronation, 5 were reduced on the first attempt and 1 was reduced on the second attempt.
                In the reduction of radial head subluxations, the hyperpronation technique required fewer attempts at reduction compared with supination, was successful more often than supination, and was often successful when supination failed. To determine whether reduction of radial head subluxation (RHS) is more successful using pronation and flexion (PF) vs the more widely used supination and flexion (SF) method.
                Prospective study in a tertiary care children's hospital ED from August 1996 through December 1997. Inclusion criteria included age <7 years with an upper-extremity injury. Exclusion criteria included neurologic impairment, congenital malformation, or obvious bony deformity or edema. Patients were randomized to receive either PF or SF. Reduction was considered successful if the child used the injured arm. Both the physician and the parent rated the child's pain during the procedure using a descriptive ordinal scale, from 0 (no pain) to 3 (severe pain).
                148 patients were enrolled; 13 were excluded. Success was achieved on the first attempt in 53/67 (80%, 95% CI = 0.67 to 0.88) of patients receiving PF and in 47/68 (69%, 95% CI = 0.57 to 0.80) of those receiving SF (p = 0.186). For those injuring the left arm, 29/41 (71%, 95% CI = 0.54 to 0.84) were successfully reduced using SF, while 33/37 (89%, 95% CI = 0.75 to 0.97) were successfully reduced using PF (p = 0.044). Physicians perceived PF to be less painful than SF (p = 0.013). There was no significant pain score difference rated by parents.
                Both PF and SF can be used with success to reduce RHS. For left arm injuries, PF should be attempted first, since it may decrease the need for further treatment. PF may be less painful, particularly for first reduction attempts.
There is limited evidence from four small low-quality trials that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children. We recommend that a high quality randomised trial be performed to strengthen the evidence.