Hyperpronation Romps Supination-Flexion

December 21, 2016

Short Attention Span Summary

Supination schmupination
This meta-analysis found hyperpronation for nursemaid’s elbow was better than supination/flexion – a lot better.  The aggregate failure rate for hyperpronation was 9%; for supination/flexion it was 27%.  Authors calculated a NNT of 4.

Spoon Feed
Hyperpronation beats supination/flexion for nursemaid’s elbow.  My anecdotal experience is that it’s also less painful…but take that with a grain of salt.

My technique is to keep the arm in the position of comfort, which is universally adducted against the trunk, flexed at the elbow, with the hand slightly pronated.  If it’s the patient’s right arm, I face the patient and support their right elbow with my left hand and place a little pressure over the radial head with my thumb.  Meanwhile, with my right hand, I firmly exaggerate the pronation of the hand and wrist.  There is almost always a slight palpable click at the radial head to indicate reduction.  Then step back and get ready for a high five both from the patient and his or her adoring parents.

EM Lit of Note has a summary of this as well.  Here is a video of the reduction on You Tube.  Note, it is a little different than I do it.  You don’t have to fully extend to use hyperpronation, and a little pressure over the radial head may help.

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Abstract

Am J Emerg Med. 2016 Nov 2. pii: S0735-6757(16)30775-6. doi: 10.1016/j.ajem.2016.10.059. [Epub ahead of print]

Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis.

Bexkens R1, Washburn FJ2, Eygendaal D3, van den Bekerom MP4, Oh LS5.

Author information:

1Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. Electronic address: rbexkens@mgh.harvard.edu.

2Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA 02114, USA. Electronic address: frederic.washburn@gmail.com.

3Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands; Department of Orthopaedic Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. Electronic address: deygendaal@amphia.nl.

4Department of Orthopaedic Surgery, Shoulder and Elbow Unit, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands. Electronic address: bekerom@gmail.com.

5Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA 02114, USA. Electronic address: loh@mgh.harvard.edu.

Abstract

BACKGROUND/AIM:

Nursemaid’s elbow usually occurs in young children when longitudinal traction is placed on the arm. Several manipulative maneuvers have been described, although, the most effective treatment technique is yet unclear. The aim of this systematic review and meta-analysis was to compare the two most commonly performed maneuvers (supination-flexion and hyperpronation) in the treatment of nursemaid’s elbow.

METHODS:

A literature search was performed in PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing supination-flexion and hyperpronation. Data were extracted and pooled independently by two authors. Methodological quality assessment of included studies was performed. Meta-analysis was performed using a fixed-effect model in case of homogeneity across studies, and using a random-effect model in case of heterogeneity. Heterogeneity was calculated with the χ2 test and inconsistency in study effects across trials was quantified by I2 values.

RESULTS:

Seven randomized trials, including 701 patients (62% female), were included. A total of 350 patients were treated with the hyperpronation maneuver versus 351 patients who underwent the supination-flexion maneuver. Meta-analysis showed that hyperpronation was more effective than supination-flexion (risk ratio, 0.34; 95% confidence interval, 0.23 to 0.49; I2, 35%). The absolute risk difference between maneuvers was 26% in favor of hyperpronation, resulting in a number needed to treat of 4 patients. Trials lacked blinding of assessors and universal pain measures.

CONCLUSIONS:

Hyperpronation was more effective in terms of success rate and seems to be less painful compared to the supination-flexion maneuver in children with nursemaid’s elbow.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27836316 [PubMed – as supplied by publisher]