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Reduction of pulled elbows
  1. David Lewis, East Anglian Trainees,
  2. Jon Argall, Senior Clinical Fellow,
  3. K Mackway-Jones
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones{at}

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    Report by David Lewis, East Anglian Trainees
 Checked by Jon Argall, Senior Clinical Fellow


    A short cut review was carried out to establish whether a pronation manoeuvre is better than a supination manoeuvre for first time reduction of pulled elbow. Altogether 57 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

    Clinical scenario

    A 2 year old child is brought into the emergency department by her parents. They tell you that she has not used her left arm since tripping over while holding her older sister's hand. The child is holding her left arm flexed at the elbow and semi-prone. The diagnosis is clearly a pulled elbow. You have heard various colleagues arguing vehemently for pronation and supination manoeuvres, and wonder which is actually the best method for reduction?

    Three part question

    In [a patient with a pulled elbow] is [a pronation manoeuvre better than a supination manoeuvre] at achieving [reduction and return to function at the first attempt]?

    Search strategy

    Medline 1966–10/02 using the OVID interface. [exp Elbow OR exp Elbow joint OR] AND [exp adolescence OR exp child OR exp child of impaired parents OR exp child, abandoned OR exp child, exceptional OR exp child, hospitalized OR exp child, institutionalized OR exp child, preschool OR exp child, unwanted OR exp disabled children OR exp homeless youth OR exp infant OR exp only child OR child$.mp Or exp Pediatrics OR pediatric$.mp OR paediatric$.mp] AND [exp Dislocations OR OR] AND [exp Manipulation, orthopedic OR OR exp Pronation OR OR exp Supination OR] LIMIT to human AND English.

    Search outcome

    Altogether 57 papers were found of which 54 were irrelevant or of insufficient quality. The remaining three were all randomised controlled trials. One of these was looking at supination with flexion compared with extension. The remaining two papers are shown in table 1.

    Table 1


    The classic method for reduction of pulled elbows is supination at the wrist followed by flexion at the elbow. There has been no difference demonstrated between flexion and extension during this manoeuvre. When studying a practical procedure it is impossible to exclude all bias and this may weaken these results.

    ▸ Clinical bottom line

    Pronation with or without elbow flexion is the first line method of reduction for pulled elbows.

    Report by David Lewis, East Anglian Trainees
 Checked by Jon Argall, Senior Clinical Fellow


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