In summary, for pediatric patients treated using hyperpronation compared to supination:

Benefits in NNT

  • 17% lower rate of first-attempt failures
  • 17% lower rate of second-attempt failures
  • NNT of 6 for preventing one first-attempt failure
  • NNT of 6 for preventing one second-attempt failure

Harms in NNT

    Not applicable: Data on harms were not reported
    Not applicable: Data on harms were not reported

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Source: Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2017 Jul 28;7:CD007759.

Study Population: 906 children with radial head subluxation from 8 studies with an average age of two years old

Efficacy Endpoints: First-attempt reduction failure, continued failure after a second attempt with the same technique

Harm Endpoints: Not applicable: Data on harms were not reported

Narrative: Radial head subluxation (also referred to as “nursemaid’s elbow” or “pulled elbow”) is a common pediatric injury with an overall incidence of 1.2% per year among children less than five years of age.1, 2, 3 The injury occurs when the annular ligament becomes entrapped between the head of the radius and the capitellum, resulting in sudden loss of function at the elbow (Hagroo 1995). Reduction is commonly performed using one of two different methods: 1) supination (external rotation of the forearm) followed by flexion (most commonly) or extension at the elbow, or 2) hyperpronation (internal rotation of the forearm while the elbow is extended).4

The Cochrane review discussed here assessed randomized and quasi-randomized controlled trials comparing different manipulative interventions for radial head subluxation in pediatric patients.4 The primary outcome was reduction failure after the first attempt, defined as the need for another reduction attempt or lack of spontaneous use of the arm by the child. Treatment success was defined as immediate restoration of a pain-free, fully functioning arm. Continued failure after a second attempt with the same technique was also reported as an outcome measure.

Failure of reduction on the first attempt occurred in 37 out of 402 patients (9.2%) with hyperpronation and 108 out of 409 patients (26.4%) with supination, resulting in a number-needed-to-treat of 6 in favor of hyperpronation (absolute risk difference [ARD]: 17%; relative risk [RR]: 0.35, 95% CI 0.25 to 0.50; low quality evidence).

Continued failure after a second attempt using same procedure as before occurred in 9 out of 302 patients (3.0%) with hyperpronation and 64 out of 322 patients (19.9%), resulting in a needed-to-treat of 6 in favor of hyperpronation (ARD: 17%; RR: 0.16, 95% CI 0.09 to 0.32; very low quality evidence).

Caveats: The overall quality of the trials included in the meta-analysis was low due to potential bias with respect to random sequence generation, allocation concealment, and blinding. Over half of the included trials were quasi-randomized (e.g., selected based upon day of the week or patient birthday). Additionally, patients, providers, and outcome assessors were not blinded in any of the studies. While it would be nearly impossible to blind the patients or providers, blinding the outcome assessors would have reduced potential bias. Moreover, none of the trials were registered and a priori protocols were not available, leading to potential selective reporting bias. There were also differences in provider training and experience, and it is unclear whether this may have influenced the success of each technique. Authors of the systematic review were unable to assess planned subgroup analyses for age and clinical setting. They were also unable to compare other important secondary outcomes, such as pain, bruising, or recurrence because none of the trials reported on this data. Outcomes pertaining to pain and ultimate treatment failure were inconsistently reported and were not included in the meta-analysis.

Based on the existing evidence, hyperpronation appears superior to supination for the treatment of radial head subluxation. While further, high-quality trials are needed, the large difference and consistent benefit across trials suggests that hyperpronation should be considered as the first-line technique for the reduction of radial head subluxation depending upon provider comfort and experience. Therefore, we have assigned a color recommendation of Green (Benefit > Harm) to pronation maneuver for reducing radial head subluxation.

Author: Michael Gottlieb, MD; Alex Koyfman, MD; Brit Long, MD

Supervising editor: Allan Wolfson, MD

Published/Updated: January 11, 2019

  1. The Title Bar

    The title bar is color-coded with our overall recommendation.

    • Green: Benefits outweigh risks.
    • Yellow: Unclear risk/benefit profile.
    • Red: Benefits do not outweigh risks.
    • Black: Obvious harms, no clear benefits.
  2. Tip content...