We've all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child's arm is either broken or dislocated. We all recognize this as radial head subluxation or "nursemaid's elbow" and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? Does the parent scream and threaten to sue? What if nothing happens?
Trick of the Trade: Hyperpronation technique
A 2009 paper by Bek et al. describes a method of pronation instead of supination. The proposed maneuver involves one hand holding the elbow at 90 degrees of flexion and the other hand holding the wrist. The wrist is then hyperpronated to complete the reduction.
Sixty-six patients were randomized to either a traditional reduction or the hyperpronation maneuver. If the initial attempt failed, a second attempt was performed. If the second attempt failed, then the alternate method was performed. Bottom line...hyperpronation was 94% successful on the first attempt compared to supination-flexion at 69%. Three patients failed supination-flexion (first and second attempt) but were successfully reduced with hyperpronation on the first attempt. Hyperpronation was also subjectively rated as significantly easier then supination-flexion by the practitioner.
I've been using hyperpronation for the past several years and love it. The maneuver appears less traumatic on the child (and parent).
Has anyone else tried it? I'd love to hear your experiences!
Reference
Bek D et al. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial European Journal of Emergency Medicine. 2009, 16(3), 135-8. DOI: 10.1097/MEJ.0b013e32831d796a
Great post, Fred. I only recently started using the hyperpronation approach. It works really well. Agreed.
ReplyDeleteI do the hyper-pronation maneuver also and find it effective. It also seems to cause a little less crying.
ReplyDeleteAs a general challenge to dogma I am compelled to point out that it may in fact be a myth that nursemaids elbow requires reduction at all. Since there is virtually no possibility of poor outcome with any (and even perhaps no) technique I am not sure that there is an compelling evidence to mandate any one technique. I suspect that forcing the child to move the elbow around in any way at all carries a fairly high chance of reduction...
Interesting challenge, Dr. J. I suspect that you are right about just leaving things the way they are. with virtually no down side.
ReplyDeleteThe tricky thing is when patients who present with a POSSIBLE nursemaid elbow. Things may not be as clear cut in patients who also sustain blunt trauma to the same elbow along with twisting). If the pronation reduction technique doesn't work, one should probably take an xray to make sure it's not a subtle supracondylar fracture.
Half the time the x-ray tech fixes it because an x-ray is ordered from triage. There is manipulation for the study and voila, the arm is reduced.
ReplyDeleteMichelle - Agree that it gets trickier when there is a history of blunt trauma (such as a fall). I do exactly what you do.
I will try it! Your trick it's tanslated in Italian now.
ReplyDeleteGemma - Great. Thanks!
ReplyDeleten = 2 100% success with very minimal crying/distress on behalf of the young patients.
ReplyDelete@Kath...glad to hear of your success with the maneuver!
ReplyDelete@Kath - yup, I love this as well. n=5.
ReplyDeleteThere's evidence to support hyperpronation/extension over hypersupination/flexion @ http://www.ncbi.nlm.nih.gov/pubmed/9651462 .
ReplyDeleteThe key is that the former method only works in full locked extension, not almost-extension because the child is crying. Excellent work!
-T
Even more evidence to support the hyperpronation technique! Thanks, Todd. Didn't know about the full-extension caveat for the former technique.
ReplyDeletefull extension as in 180 degrees?
ReplyDeleteThere are 2 schools of thought on the hyperpronation technique. Many of us do this in a full-extension. That means 180 degrees (straightened arm).
ReplyDeleteOh and the other school of thought is to do this at 90 degrees bent elbow. I find that this doesn't work as well.
ReplyDeleteUpdated Cochrane Review of 4 trials here: http://www.ncbi.nlm.nih.gov/pubmed/22258973
ReplyDeleteThanks! Looks seems to suggest that the pronation technique is better.
ReplyDeleteMAIN RESULTS:
One trial with 66 children was newly included in this update. Overall, four trials with 379 children, all younger than seven years old, were included. All four trials compared pronation versus supination. One trial was at high risk of selection bias because allocation was not concealed and all four trials were at high risk of detection bias due to the lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (21/177 versus 47/181, risk ratio 0.45; 95% confidence interval 0.28 to 0.73). Pain perception was reported by two trials but data were unavailable for pooling. Both studies concluded that the pronation technique was less painful than the supination technique.
AUTHORS' CONCLUSIONS:
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.
I will have to try this hyperpronation technique.
ReplyDeleteThese are usually easy to fix from what I have found is that even if you get reduction they may still not want to the arm for a few minutes. I like to wait and go back in the room with some stickers or something and they usually reach right out with the injured arm and grab them then parents are happy and it's time for DC!
Brian...in my experience, hyperpronation appears less traumatic for all parties involved. I incorporate it into my exam so parents don't even know that it's been reduced. Agree with leaving the room as kids are usually happier in general when I'm not there! Thanks for your comments.
ReplyDeleteInterestingly, this method is the one I have been using since it was taught to me during my pediatric residency by wise pedi ER docs. I never have used the forced supination technique because the pronation technique works so well. I do hesitate and order xrays first if the mechanism doesn't sound right - I fear mucking up a supracondylar and inducing neurovascular complications (I wonder if there's a study on that?) - but I have literally never failed to reduce a nursemaid's with this method.
ReplyDeleteGreat feedback. I don't see many pediatric patients where I am. Sounds like a no-brainer to use the pronation technique.
DeleteAgree that if the story doesn't sound right, go for the xray first. I've only used pronation for the past several years and haven't had any failures (yet).
DeleteThanks for your comments!
I just used it and it worked like a champ. Much better experience for the child (and me) than my prior supination maneuvers!
ReplyDeleteThanks for the tip!
Jeff Jarvis
Glad it worked well for you!
DeleteNot a doctor, folks, but a mom of a repeating visitor to the urgent care for this issue. I cringed as I watched my two year old go through several attempts at reduction. After going home and watching my usually active toddler refuse to move the arm for four or five days, I got desperate for a better method. Moms know the difference between the whimper of fear and a gasp of real pain. Thank you for the clear article. I tried this maneuver very gently and it worked immediately. There was a small pop as if a knuckle had popped and he was using it within five minutes. I don't think we will revisit the urgent care for this again unless they read this article in my presence first. Thank you again.
ReplyDeleteWow, thanks for your comments and feedback. I'm glad that things went well.
Delete