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Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom‐Smit LWA, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev 2017; 7:CD007759. [PMID: 28753234 PMCID: PMC6483272 DOI: 10.1002/14651858.cd007759.pub4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pulled elbow (nursemaid's elbow) is a common injury in young children. It often 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. It can also be caused by a fall or twist. 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 commonly, supination of the forearm, often combined with flexion, and (hyper-)pronation. It is unclear which is most successful. This is an update of a Cochrane review first published in 2009 and last updated in 2011. OBJECTIVES To compare the effects (benefits and harms) 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: September 2016. SELECTION CRITERIA 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, assessed risk of bias, and extracted data. We pooled data using a fixed-effect model. MAIN RESULTS Overall, nine trials with 906 children (all younger than seven years old and 58% of whom were female) were included, of which five trials were newly identified in this update. Eight trials were performed in emergency departments or ambulatory care centres, and one was performed in a tertiary paediatric orthopaedic unit. Four trials were conducted in the USA, three in Turkey, one in Iran, and one in Spain. Five trials were at high risk of selection bias because allocation was not concealed and all trials were at high risk of detection bias due to the lack of assessor blinding. Eight trials compared hyperpronation with supination-flexion. We found low-quality evidence that hyperpronation resulted in less failure at first attempt than supination-flexion (9.2% versus 26.4%, risk ratio (RR) 0.35; 95% confidence interval (CI) 0.25 to 0.50; 811 participants, 8 studies). Based on an illustrative risk of 268 failures at first attempt per 1000 children treated using supination-flexion, this amounted to 174 fewer failures per 1000 children treated using hyperpronation (95% CI 134 to 201 fewer). Based on risk differences data, we also estimated a number needed to treat of 6 (95% CI 5 to 8); this means that six children would need to be treated with the hyperpronation method rather than the supination-flexion method to avoid one additional failure at the first attempt.The very low-quality evidence (from four studies) for pain during or after manipulation means that it is uncertain whether there is or is not a difference between pronation and supination-flexion. There was very low-quality evidence from six studies that repeat pronation may be more effective than repeat supination-flexion for the second attempt after initial failure. The remaining outcomes were either not reported (adverse effects, recurrence) or unsuitable for pooling (ultimate failure). Ultimate failure, reported for the overall population only because of the differences in the study protocols with respect to what to do after the first attempt failed, ranged from no ultimate failures in two studies to six failures (4.1% of 148 episodes) in one study.One trial compared supination-extension versus supination-flexion. It provided very low-quality evidence (downgraded three levels for very serious risk of bias and serious imprecision) of no clear difference in failure at first attempt between the two methods. AUTHORS' CONCLUSIONS There was low-quality evidence from eight small trials that the pronation method may be more effective at first attempt than the supination method for manipulating pulled elbow in young children. For other outcomes, no conclusions could be drawn either because of very low-quality evidence or the outcomes not being reported. We suggest that a high-quality randomised clinical trial comparing hyperpronation and supination-flexion is required to provide definitive evidence. We recommend that this is preceded by a survey among clinicians to establish the extent of clinical equipoise and to optimise the study design and recruitment.
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Affiliation(s)
- Marjolein Krul
- Erasmus Medical CenterDepartment of General PracticePO Box 2040RotterdamNetherlands3000 CA
| | - Johannes C van der Wouden
- VU University Medical CenterDepartment of General Practice and Elderly Care Medicine, Amsterdam Public Health Research InstitutePO Box 7057AmsterdamNetherlands1007 MB
| | - Emma J Kruithof
- VU University Medical CenterDepartment of General Practice and Elderly Care Medicine, Amsterdam Public Health Research InstitutePO Box 7057AmsterdamNetherlands1007 MB
| | - Lisette WA van Suijlekom‐Smit
- Erasmus Medical Center ‐ Sophia Children's HospitalDepartment of Paediatrics, Paediatric RheumatologyPO Box 2060RotterdamNetherlands3000 CB
| | - Bart W Koes
- Erasmus Medical CenterDepartment of General PracticePO Box 2040RotterdamNetherlands3000 CA
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Bexkens R, Washburn FJ, Eygendaal D, van den Bekerom MP, Oh LS. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis. Am J Emerg Med 2017; 35:159-163. [DOI: 10.1016/j.ajem.2016.10.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 10/24/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022] Open
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Wang J, Jiang LD, He AY, Wang DR, Zhu J, Duan RS, Tao C. Annular ligament reconstruction by suture anchor for treatment of radial head dislocation in children. BMC Musculoskelet Disord 2015; 16:181. [PMID: 26242600 PMCID: PMC4525736 DOI: 10.1186/s12891-015-0642-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 07/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We investigated the efficacy of annular ligament reconstruction by suture anchor in the treatment of radial head dislocation (RHD) in children. METHOD A total of 20 RHD children nderwent annular ligament reconstruction surgery using suture anchor. Preoperative and postoperative elbow functions were evaluated according to Broberg and Morrey 100-point scale. Recovery of radial nerve function was assessed using the Chinese Medical Association of Hand Surgery Branch of Upper Limb Functional Assessment Standard. All statistical analyses were performed using SPSS version 17.0 software. RESULTS All 20 RHD children who underwent the procedure were followed up for a median duration of 24 months. At the last follow-up, the average Broberg-Morrey score was 94.3, with 12 children (60.0%) showing excellent outcomes (score range, 95 to 100), 7 children (35.0%) showing good outcomes (score range, 80 to 94), 1 child (5.0%) displayed a fair outcome (score range, 60 to 79), and 0 (0%) poor outcome. A significant difference in the excellent-good rate was observed when the elbow function before surgery was compared to after surgery (χ(2) = 5.559, P = 0.018). The radial nerve function of the 13 RHD children with radial nerve injury also recovered to normal. Among these 13 RHD children, nine exhibited excellent outcomes, 3 showed good outcomes, 1 displayed a fair outcome, and no patient showed a poor outcome. A significant difference in the excellent-good rate of radial nerve function was also observed when before surgery was compared to after surgery in these RHD children (χ(2) = 4.887, P = 0.027). CONCLUSION Our results strongly indicated that suture anchor is highly effective for reconstruction of the annular ligament and to promote full functional recovery in RHD children, demonstrating that the procedure is an excellent treatment choice in RHD children.
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Affiliation(s)
- Jian Wang
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Middle Renmin Road No.139, Changsha, 410011, People's Republic of China.
| | - Liang-Dong Jiang
- Department of Orthopedics, Changsha Central Hospital, Changsha, 410004, People's Republic of China.
| | - Ai-Yong He
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Middle Renmin Road No.139, Changsha, 410011, People's Republic of China.
| | - Dai-Rong Wang
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Middle Renmin Road No.139, Changsha, 410011, People's Republic of China.
| | - Jun Zhu
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Middle Renmin Road No.139, Changsha, 410011, People's Republic of China.
| | - Run-Shan Duan
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Middle Renmin Road No.139, Changsha, 410011, People's Republic of China.
| | - Cheng Tao
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Middle Renmin Road No.139, Changsha, 410011, People's Republic of China.
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Thornton MD, Della-Giustina K, Aronson PL. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 2015; 33:423-49. [PMID: 25892730 DOI: 10.1016/j.emc.2014.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Orthopedic injuries in children are unique when compared to those of adults because of the physiologic differences, especially the growth plates, stronger periosteum, and dynamic state of growth. The approach to the orthopedically injured child requires a gentle yet thorough focus with consideration of the growth plates as a primary area of weakness and growth when the child sustains an injury. Understanding the developmental stages of bones is paramount to being able to manage any injuries. Finally, what appears to be a benign injury may portend more serious issues, because nonaccidental trauma must always be considered in the evaluation of the injured child.
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Affiliation(s)
- Matthew D Thornton
- Department of Emergency Medicine, Bay State Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Karen Della-Giustina
- Department of Emergency Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA.
| | - Paul L Aronson
- Department of Pediatric Emergency Medicine, Yale New Haven Childrens Hospital, 100 York Street, Suite 1F, New Haven, CT 06511, USA
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Pronation douloureuse. ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0520-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Elbow fractures are common in pediatric patients. Most injuries to the pediatric elbow are stable and require simple immobilization; however, more severe fractures can occur, often requiring operative stabilization and/or close monitoring. This article highlights the common fractures and dislocations about the pediatric elbow and discusses the history, evaluation, and treatment options for specific injuries.
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Affiliation(s)
- Kevin J Little
- Division of Pediatric Orthopaedics, Hand and Upper Extremity Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2017, Cincinnati, OH 45229, USA; Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45229, USA.
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Irie T, Sono T, Hayama Y, Matsumoto T, Matsushita M. Investigation on 2331 cases of pulled elbow over the last 10 years. Pediatr Rep 2014; 6:5090. [PMID: 24987508 PMCID: PMC4076648 DOI: 10.4081/pr.2014.5090] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 12/29/2013] [Accepted: 12/30/2013] [Indexed: 11/22/2022] Open
Abstract
Pulled elbow is a common upper extremity injury in children. We present a retrospective study of 2331 pulled elbow cases examined in our hospital over the last ten years. All pediatric patients with a diagnosis of pulled elbow from January 2002 to December 2011 were retrospectively reviewed according to sex, age, affected arm, recurrence rate, mechanism of injury and treatment outcomes. There is no significant sex difference. The frequency of injury peaked for both boys and girls at 6 months and 2 years of age. The left arm was more affected than the right. The recurrence rate was 14%. In about 50% of cases, the cause of injury was forcible traction to the forearm. Almost all of the splinted patients, caused by severe pain or lack of mobility of the affected limb following reduction, recovered within 2 weeks, but 2 were later diagnosed with a fracture. For infants less than 1 year old, injury can often occur when rolling over. For children 1 year old or older the left arm is more commonly affected, and the frequency of injuries to the left arm increases with age, possibly because the left hand is commonly held by the guardian's dominant right hand and faster development of muscle strength in the child's dominant right arm works toward preventing injury to that arm with age.
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Affiliation(s)
- Takashi Irie
- Department of Orthopedic Surgery, Kurashiki Central Hospital , Kurashiki, Japan
| | - Takashi Sono
- Department of Orthopedic Surgery, Kurashiki Central Hospital , Kurashiki, Japan
| | - Yousuke Hayama
- Department of Pediatrics, Kurashiki Central Hospital , Kurashiki, Japan
| | - Taiichi Matsumoto
- Department of Orthopedic Surgery, Kurashiki Central Hospital , Kurashiki, Japan
| | - Mutsumi Matsushita
- Department of Orthopedic Surgery, Kurashiki Central Hospital , Kurashiki, Japan
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Dixon A, Clarkin C, Barrowman N, Correll R, Osmond MH, Plint AC. Reduction of radial-head subluxation in children by triage nurses in the emergency department: a cluster-randomized controlled trial. CMAJ 2014; 186:E317-23. [PMID: 24664649 DOI: 10.1503/cmaj.131101] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Radial-head subluxation is an easily identified and treated injury. We investigated whether triage nurses in the emergency department can safely reduce radial-head subluxation at rates that are not substantially lower than those of emergency department physicians. METHODS We performed an open, noninferiority, cluster-randomized control trial. Children aged 6 years and younger who presented to the emergency department with a presentation consistent with radial-head subluxation and who had sustained a known injury in the previous 12 hours were assigned to either nurse-initiated or physician-initiated treatment, depending on the day. The primary outcome was the proportion of children who had a successful reduction (return to normal arm usage). We used a noninferiority margin of 10%. RESULTS In total, 268 children were eligible for inclusion and 245 were included in the final analysis. Of the children assigned to receive physician-initiated care, 96.7% (117/121) had a successful reduction performed by a physician. Of the children assigned to receive nurse-treatment care, 84.7% (105/124) had a successful reduction performed by a nurse. The difference in the proportion of successful radial head subluxations between the groups was 12.0% (95% confidence interval [CI] 4.8% to 19.7%). Noninferiority of nurse-initiated radial head subluxation was not shown. INTERPRETATION In this trial, the rate of successful radial-head subluxation performed by nurses was inferior to the physician success rate. Although the success rate in the nurse-initiated care group did not meet the non-inferiority margin, nurses were able to reduce radial head subluxation for almost 85% of children who presented with probable radial-head subluxation. TRIAL REGISTRATION Clinical Trials.gov, no. NCT00993954.
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Affiliation(s)
- Andrew Dixon
- Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont.
| | - Chantalle Clarkin
- Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont
| | - Nick Barrowman
- Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont
| | - Rhonda Correll
- Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont
| | - Martin H Osmond
- Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont
| | - Amy C Plint
- Department of Pediatrics (Dixon), University of Alberta; Stollery Children's Hospital (Dixon), Edmonton, Alta.; Clinical Research Unit (Barrowman), Children's Hospital of Eastern Ontario Research Institute; Children's Hospital of Eastern Ontario Research Institute (Clarkin, Correll, Osmond, Plint), Ottawa, Ont.; Department of Pediatrics and Emergency Medicine (Osmond, Plint), University of Ottawa, Ottawa, Ont
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Abstract
BACKGROUND Pulled elbow is a common injury in children under the age of 5 years which is usually treated by manual reduction. Supination of the forearm is recommended as opposed to pronation or other maneuvers. The author has developed a manipulative intervention for reduction of pulled elbow in young children on the basis of the pronation technique and called ProFI reduction. PATIENTS AND METHODS The ProFI method was performed on 41 children and the group was analyzed prospectively according to effectiveness of the ProFI repositioning. RESULTS Among the 41 children the initial diagnosis was incorrect in 7 cases (17%) and in 11 children (27%) more than one doctor's visit was necessary to reposition successfully. Repositioning with the ProFI method was immediately successful in all cases. CONCLUSION The application of the ProFI method as a modified pronation technique was shown to provide excellent effectiveness with respect to the patients treated.
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Affiliation(s)
- T Ruffing
- Klinik für Unfallchirurgie und Orthopädie 1, Westpfalz-Klinikum GmbH, Hellmut-Hartert-Str. 1, 67655, Kaiserslautern, Deutschland,
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