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Updated: May 25, 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 W A van Suijlekom-Smit
1Department of General Practice, ErasmusMedical Center, Rotterdam, Netherlands. m.krul@erasmusmc.nl.
Insights
Pronation may be a more effective and less painful method for treating pulled elbow (nursemaid
Area of Science:
- Pediatrics
- Orthopedics
- Musculoskeletal Disorders
Background:
- Pulled elbow (nursemaid's elbow) is a common pediatric injury caused by a sudden pull on the arm.
- This injury results in subluxation of the radial head, leading to acute pain and arm dysfunction.
- Current treatment involves manual reduction, with supination often recommended, but effectiveness is unclear.
Purpose of the Study:
- To compare the effectiveness and painfulness of different manipulative techniques for treating pulled elbow in young children.
- To update a previous Cochrane review on this topic.
Main Methods:
- Systematic review and meta-analysis of randomized and quasi-randomized controlled trials.
- Searched multiple databases including Cochrane, MEDLINE, EMBASE, and CINAHL up to July 2011.
- Included four trials involving 379 children under seven years old, comparing pronation and supination techniques.
Main Results:
- Pronation demonstrated statistically significantly lower failure rates compared to supination (RR 0.45; 95% CI 0.28 to 0.73).
- Two trials reported pain perception, with both concluding that the pronation technique was less painful.
- All included trials had a high risk of bias, particularly in selection and detection.
Conclusions:
- Limited evidence from low-quality trials suggests pronation may be more effective and less painful than supination for pulled elbow reduction.
- A high-quality randomized controlled trial is recommended to strengthen the evidence base.
- Further research is needed to definitively establish the optimal manipulation technique.
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. This is an update of a Cochrane review first published in 2009.
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 Methods:
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: July 2011.
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:
One trial with 66 children was newly included in this update. Overall, four trials with 379 children, all younger than seven years old, were included. All four trials compared pronation versus supination. One trial was at high risk of selection bias because allocation was not concealed and all four trials were at high risk of detection bias due to the lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (21/177 versus 47/181, risk ratio 0.45; 95% confidence interval 0.28 to 0.73). 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 four 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. We recommend that a high quality randomised trial be performed to strengthen the evidence.
