Nursemaid’s Elbow Reduction – Which Technique is Better?

Written by Nickolas Srica

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The hyperpronation maneuver so significantly outperformed supination/flexion for radial head subluxation in this randomized clinical trial that it was stopped early.

Why’d you pull on my arm? The nursemaid me do it…
Radial head subluxation (RHS), or “nursemaid’s elbow”, is a common musculoskeletal pathology encountered in pediatric patients that often occurs from sudden pulling on the outstretched arm. For reduction, the two major maneuvers that are often utilized are the hyperpronation (HP) and the supination/flexion (SF) techniques, but which actually has superior first-attempt success? This randomized trial took place at a tertiary training hospital in Turkey where children ages 0-6 years diagnosed with RHS were randomized to reduction with either the SF maneuver or the HP maneuver. The HP group ultimately had a significantly lower first-attempt failure rate than the SF group (9.8% vs 24.2%, RR 0.41; 95%CI 0.19-0.98, p=0.037), leading to an early ending of the trial. None of the secondary outcomes that were analyzed (second/third attempt failure rates, patient comfort, recurrence within 72 hours) showed any statistical difference between groups. The trial was fairly well done, where clinicians were trained on both maneuvers ahead of time, allocation concealment was employed, and outcome assessors and statisticians were blinded to which maneuver was utilized. However, a single-center design and no assessment of the consistency of success rates across the two methods for the performing clinicians were limitations.

How does this change my practice?
In clinical practice I’ve typically done a first attempt “combination” of hyperpronation immediately followed by supination/flexion when reducing these with good anecdotal success, but based on this and other recent evidence, it appears hyperpronation is likely the way to go.

Source
Comparison of supination/flexion maneuver to hyperpronation maneuver in the reduction of radial head subluxations: A randomized clinical trial. Am J Emerg Med. 2025 Feb;88:29-33. doi: 10.1016/j.ajem.2024.11.026. Epub 2024 Nov 18. PMID: 39579408