What is the recommended technique for reducing a pulled elbow in a pediatric patient?

Pulled Elbow Reduction Technique

The hyperpronation technique should be used as the first-line reduction maneuver for pulled elbow (nursemaid's elbow) in children, as it achieves higher first-attempt success rates (93-98%) compared to the traditional supination-flexion technique (77-80%) and is less painful. 1, 2, 3

Recommended Reduction Technique: Hyperpronation

Perform the hyperpronation maneuver first:

• Hold the child's elbow at 90 degrees of flexion with one hand stabilizing the elbow
• With your other hand, firmly pronate the wrist (turn the palm downward)
• A palpable click often indicates successful reduction
• The child should regain full use of the arm within 15 minutes if successful 2, 4

Success Rates and Evidence Quality

The hyperpronation technique demonstrates superior outcomes:

• First-attempt success rate: 93.84% to 97.5% compared to 77-80% for supination-flexion 2, 3
• Overall success rate of 97.5% versus 86% for supination-flexion 2
• When supination-flexion fails, hyperpronation succeeds in most cases (5 of 6 patients in one study) 2
• A Cochrane review found pronation resulted in significantly less failure (risk ratio 0.45,95% CI 0.28-0.73) 1

Alternative Technique: Supination-Flexion

If hyperpronation fails after two attempts, use supination-flexion:

• Hold the elbow at 90 degrees with one hand
• With the other hand, rapidly supinate the forearm (turn palm upward)
• Then flex the elbow fully
• Again, wait 15 minutes to assess for return of function 2, 4

Management Algorithm

Follow this stepwise approach:

1. Attempt hyperpronation reduction (first attempt)
2. If unsuccessful after 15 minutes, repeat hyperpronation (second attempt)
3. If still unsuccessful after another 15 minutes, switch to supination-flexion
4. If two trials of both techniques fail, splint the arm and refer for radiographic evaluation to exclude fracture 4

Critical Clinical Considerations

Prior manipulation significantly reduces success rates:

• 100% of hyperpronation failures and 80% of supination-flexion failures had undergone prior manipulation attempts 3
• Conversely, 93-97% of successful first-attempt reductions occurred in children without prior manipulation 3
• This emphasizes the importance of using the correct technique on the first attempt

Pain perception:

• Both studies reporting pain found hyperpronation less painful than supination-flexion, though quantitative data were not available for pooling 1

Common Pitfalls to Avoid

• Do not send to emergency department unnecessarily - this can be managed in the office setting with 80% success rate and no complications 4
• Do not start with supination-flexion - the traditional technique is inferior and should be reserved for when hyperpronation fails 2, 3
• Do not perform excessive manipulation attempts - if unsuccessful after two attempts with each technique, obtain imaging to exclude fracture 4
• Educate parents to avoid swinging children by their hands, which causes this injury 4

Evidence Quality Note

While the Cochrane review identified that all four included trials had high risk of selection and detection bias due to lack of allocation concealment and assessor blinding, the consistency of findings across multiple studies and the large effect size support the recommendation for hyperpronation as first-line treatment 1