What is the proper technique for closed reduction of a nursemaid's elbow in a child aged 1‑4 years?

Hyperpronation Technique Should Be Used First for Nursemaid's Elbow Reduction

Use the hyperpronation (forced pronation) technique as your first-line reduction maneuver for nursemaid's elbow in children aged 1-4 years, as it has a significantly higher success rate (85-96% on first attempt) compared to the traditional supination-flexion technique (53-77% on first attempt). 1, 2, 3

The Evidence Strongly Favors Hyperpronation

A systematic review and meta-analysis of 7 randomized trials involving 701 patients demonstrated that hyperpronation was substantially more effective than supination-flexion (risk ratio 0.34,95% CI 0.23-0.49), with an absolute risk difference of 26% in favor of hyperpronation 2. This translates to a number needed to treat of only 4 patients—meaning for every 4 children treated with hyperpronation instead of supination-flexion, one additional successful reduction is achieved.

Reduction Technique Details

Hyperpronation Method (First-Line):

• Grasp the child's elbow with one hand, stabilizing it
• With your other hand, hold the child's hand/wrist
• Forcefully pronate (turn palm down) the forearm while the elbow is extended or slightly flexed
• You may feel or hear a "click" indicating successful reduction
• This is a simple, single-movement technique 1

Supination-Flexion Method (Second-Line if Hyperpronation Fails):

• Stabilize the elbow with one hand
• Supinate the forearm (turn palm up) with your other hand
• Then flex the elbow, bringing the hand toward the shoulder
• This requires two movements and is less successful

Clinical Algorithm

1. First attempt: Perform hyperpronation technique
2. If unsuccessful after 5 minutes: Repeat hyperpronation once more
3. If still unsuccessful after 15 minutes: Switch to supination-flexion technique 3
4. Success indicators: Child resumes normal arm use within 15 minutes, often accompanied by an audible or palpable "click" 4

When hyperpronation fails and you cross over to supination-flexion, success rates drop dramatically (50% vs 100% when the reverse is done) 1. Notably, when supination-flexion fails first and you switch to hyperpronation, the success rate is 83-100% 1, 4.

Pain Considerations

Both techniques appear similarly tolerable, though two studies suggested hyperpronation may be less painful 2, 5. The pain difference is not dramatic enough to change practice, but the superior efficacy of hyperpronation makes it the clear first choice.

Important Caveats

Obtain radiographs before attempting reduction in:

• Non-ambulatory infants (under 12-15 months): Nursemaid's elbow is uncommon in this age group, and fractures—including those from non-accidental trauma—are more likely 6
• Atypical mechanisms (not the classic longitudinal traction): Falls, direct blows to the elbow, or rolling over can still cause nursemaid's elbow, but maintain higher suspicion for fracture 7
• Any signs of trauma, swelling, deformity, or point tenderness suggesting fracture

Clinical diagnosis is sufficient in typical cases: A child aged 1-4 years with sudden refusal to use the arm after a pulling injury, holding the arm in slight flexion and pronation, with no focal tenderness or swelling, does not require pre-reduction radiographs 8.

Recurrence

If a child has had 3 or more episodes, counsel parents about avoiding sudden traction on the child's arm, as recurrence becomes more likely 9.