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Updated: Jun 19, 2026
A Standardized Method for Measurement of Elbow Kinesthesia
Published on: October 10, 2020
Manipulative interventions for reducing pulled elbow in young children
Marjolein Krul1, Johannes C van der Wouden, Lisette Wa van Suijlekom-Smit
1Department of General Practice, Erasmus MC, University Medical Center, PO Box 1738, Rotterdam, Zuid-Holland, Netherlands, 3000 DR.
Insights
The pronation technique for reducing pulled elbow (nursemaid's elbow) in children appears more effective and less painful than the supination method. However, more high-quality research is needed to confirm these findings.
Area of Science:
- Pediatrics
- Orthopedics
- Musculoskeletal Trauma
Background:
- Pulled elbow, or nursemaid's elbow, is a common radial head subluxation in young children caused by a sudden pull on the arm.
- Treatment typically involves manual reduction of the radial head, with various maneuvers described.
Purpose of the Study:
- To compare the effectiveness and painfulness of different manipulative interventions for pulled elbow in young children.
Main Methods:
- A systematic review of randomized and quasi-randomized controlled trials was conducted.
- Searches included major databases (Cochrane, MEDLINE, EMBASE, etc.) up to January 2009.
- The primary outcome was treatment failure on the first attempt.
Main Results:
- Three low-quality trials with 313 participants compared pronation and supination techniques.
- Pronation showed a statistically significant lower failure rate compared to supination (RR 0.53).
- Two trials suggested pronation was less painful, but data were not pooled.
Conclusions:
- Limited evidence from small, low-quality trials suggests pronation may be more effective and less painful for reducing pulled elbow.
- A small difference in effectiveness was observed.
- High-quality randomized trials are recommended to strengthen the evidence base.
Background:
Pulled 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.
Objectives:
The objective of this review is to compare the effectiveness and painfulness of the different methods used to manipulate pulled elbow in young children.
Search Strategy:
We 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 Criteria:
Any 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 Analysis:
Two review authors independently evaluated trials for inclusion and, for the included trials, independently assessed the risk of bias and extracted data.
Main Results:
Three 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' Conclusions:
There 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.
