Cochrane review: Manipulative interventions for reducing pulled elbow in young children
Authors: Krul Marjolein , van der Wouden Johannes C , van Suijlekom‐Smit Lisette WA , Koes Bart W 
Published: January 2011

AbstractBackgroundPulled elbow (nursemaid's elbow) is a common injury in young children. It results from a sudden pull on the arm, usually by an adult or taller person, which pulls the radius through the annular ligament, resulting in subluxation (partial dislocation) of the radial head. The child experiences sudden acute pain and loss of function in the affected arm. Pulled elbow is usually treated by manual reduction of the subluxed radial head. Various manoeuvres can be applied. Most textbooks recommend supination of the forearm, as opposed to pronation and other approaches. It is unclear which manoeuvre is most successful.ObjectivesThe objective of this review is to compare the effectiveness and painfulness of the different methods used to manipulate pulled elbow in young children.Search strategyWe searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, LILACS, PEDro, clinical trial registers and reference lists of articles. Date of last search: January 2009.Selection criteriaAny randomised or quasi‐randomised controlled clinical trials evaluating manipulative interventions for pulled elbow were included. Our primary outcome was failure at the first attempt, necessitating further treatment.Data collection and analysisTwo review authors independently evaluated trials for inclusion and, for the included trials, independently assessed the risk of bias and extracted data.Main resultsThree trials with 313 participants, all younger than seven years old, were included. All three trials compared pronation versus supination. The methodological quality of all three trials was low because of incomplete reporting and high risk of bias resulting from lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (risk ratio 0.53, 95% confidence interval 0.32 to 0.87). 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' conclusionsThere is limited evidence from three 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. However, only a small difference in effectiveness was found. We recommend that a high quality randomised trial be performed to strengthen the evidence.Plain Language SummaryDifferent methods of manipulation for reducing pulled elbow in young childrenPulled elbow is a dislocation of the elbow joint in a young child which is usually caused by an adult, or taller person, suddenly pulling or tugging on the child's arm when it is straight; or when a child pulls away from an adult impulsively. The child immediately complains of pain and cannot use their arm.
Treatment usually consists of manipulating the arm to get the bones of the elbow back into their correct position. It is usually treated by manual intervention. In the typical manoeuvre, called supination, the forearm is twisted or rotated outwards (palm of child's hand faces upwards), sometimes followed by bending of the elbow. While this has become standard practice, it is not always successful. Other methods, particularly the use of pronation, where the forearm is twisted or rotated inwards (palm of child's hand faces downwards), have also been used. These methods are generally safe, although bruising can occur and they can be painful.Evidence from three small, low quality trials involving a total of 313 participants indicates that the pronation method (with the hand downward) is more successful in repositioning and less painful for children with a pulled elbow.