Investigation on 2331 cases of pulled elbow over the last 10 years

The Relationship between the Bevel of the Radial Head Epiphysis and the Posterior Synovial Fringe During Rotation of the Elbow: An Ultrasonography Study with Possible Implications Regarding the Pathophysiology of Nursemaid's Elbow

BACKGROUND

Nursemaid's elbow is the most common upper extremity injury in children under 5 years of age. However, the exact pathomechanism underlying the nursemaid's elbow remains elusive, and approximate one-third of patients present with a nonclassical history. Using a high-frequency ultrasound probe, we attempted to determine the relationship between the anterior edge of the posterior synovial fringe and the peripheral rim of the radial head epiphysis during rotation. It is possible that the primary reason for the nursemaid's elbow is due to the pronator position.

METHODS

Twenty-one patients had a history of nursemaid's elbow and had a successful reduction before enrollment in this study. A high-frequency linear array 6 to 24 MHz hockey stick transducer was used to detect small morphologic changes in the peripheral rim of the radial head epiphysis and the posterior synovial fringe during rotation of the capitellum-radial joint.

RESULTS

In complete pronation, the anterior edge of the posterior synovial fringe contacts the beveled articular surface of the radial head peripheral rim in all 21 patients. In neutral and complete supination, the anterior edge of the posterior synovial fringe contacts the convexly nonarticular surface of the radial head peripheral rim and extends deep into the foveal radius. The posterior synovial fringe and the capsule-aponeurotic membrane were tightened in passive pronation in all 21 cases. The posterior synovial fringe and the capsule-aponeurosis membrane were all loose in the neutral and supination positions.

CONCLUSION

The anterior edge of the posterior synovial fringe touches the beveled peripheral rim of the radial head epiphysis during complete pronation, and the tension of the lateral collateral ligament complex during pronation may further cause unstable conditions of the anterior edge of the posterior synovial fringe. We hypothesized that the beveled peripheral rim of the radial epiphysis and its relationship with the anterior edge of the posterior synovial fringe could be the reason why nursemaid's elbow only occurs while the elbow is in the pronator position.

Understanding the recurrent pulled elbow

Nursemaid elbow is subluxation of the radius head seen in early childhood. The aim of this study was to examine the epidemiology of recurrent dislocations and the effect of hyperlaxity and bone anatomy on recurrent dislocations in these injuries, for which the pathogenesis has not been fully clarified. The study included a total of 329 paediatric patients who presented at the Paediatric Emergency Department (ED) between January 2016 and December 2022, and were diagnosed with Nursemaid Elbow. On presentation at ED, two-directional elbow radiographs were taken of all the patients and the radius head-neck ratio was measured on the lateral elbow radiograph. The Beighton score of joint hyperlaxity was evaluated in all the patients with a history of recurrent dislocation. A statistically significant difference was determined between the Beighton score groups in respect of the number of dislocations in multiple dislocations (P = 0.002). No statistically significant relationship was determined between the number of dislocations and the lateral radius head/neck ratio (P = 0.061). Hyperlaxity syndrome should be kept in mind in the aetiology of multiple dislocations.

The Usefulness of Dynamic Ultrasonography in Nursemaid's Elbow: A Prospective Case Series of 13 Patients Reconsideration of the Pathophysiology of Nursemaid's Elbow

BACKGROUND

Nursemaid's elbow is a common musculoskeletal disorder among children under 5 years of age. However, diagnostic imaging to confirm a nursemaid's elbow diagnosis is still unavailable. Through the use of a high-frequency ultrasound probe, we determined the etiology and possible pathophysiology of nursemaid's elbow.

METHODS

Thirteen consecutive patients with the clinical suspicion of nursemaid's elbows were examined. A high-frequency linear array 6 to 24 MHz hockey stick transducer was used to detect small changes (partial eclipse signs) of the radial head in the axial view before and after manipulation.

RESULTS

All patients in this study had a successful reduction. A partial eclipse sign was found in all patients before reduction and disappeared after successful reduction.

CONCLUSION

These pathologic features detected through high-frequency ultrasonography suggest the role of the escaped posterior synovial fringe in the pathogenesis of the nursemaid's elbow. The specific finding of a "partial eclipse sign" could be a useful additional clue leading to the correct diagnosis of the nursemaid's elbow and may help avoid the unnecessary reduction in patients who do not have a "partial eclipse sign".

LEVEL OF EVIDENCE

Level II, diagnostic studies.

Overutilization of Radiographs for Pulled Elbow Among Orthopedic Surgeons Compared With Pediatricians

METHODS

Electronic medical records of the largest health provider in Israel, which provides health services to more than 50% of the population, were reviewed for pulled elbow cases between 2005 and 2020. Patients aged 4.5 months to 7 years were included. Demographic information, the discipline of the treating physician, and acquisition of elbow radiographs were gathered.

RESULTS

A total of 4357 patients, 62.8% girls, were included. The average body mass index was 16.1 (SD, 1.2). Most patients were from communities in the upper half of the socioeconomic status clusters 6 to 10 (64.63%). Most patients were attended by a pediatrician (51.5%), followed by an orthopedic surgeon (19.9%). Radiographs were acquired for 570 children (13.1%). Most radiographs (36.5%) were requested by orthopedic surgeons and for children in the boundary age groups. The patient's socioeconomic status was associated with access to physicians of different subspecialties, and lower income families had a higher tendency to be treated by nonspecialized physician ( P < 0.001).

CONCLUSIONS

Orthopedic surgeons use elbow radiographs much more than pediatricians; effort should aim at reducing the imaging rate for this population.

Trends and epidemiology of radial head subluxation in the United States from 2004 to 2018

BACKGROUND

Increased body mass may predispose children to a greater risk for radial head subluxation (RHS). Recent studies in the literature have reported a plateau in obesity prevalence among infants and toddlers. This study sought to examine recent epidemiological trends in RHS incidence from 2004 to 2018 using the National Electronic Injury Surveillance System database to determine how obesity patterns may affect RHS incidence.

METHODS

The National Electronic Injury Surveillance System (NEISS) database was queried for patients 6 years of age or younger presenting with radial head subluxation between January 1, 2004 and December 31, 2018. Patient demographics, mechanisms of injury, and location of injury were recorded.

RESULTS

An estimated total 253,578 children 6 years or younger were treated for RHS with 14,204 (95% CI = 8124-20,284) in 2004 to 21,408 (95% CI = 12,882-29,934) in 2018. The overall annual rate of RHS per 10,000 children ≤ 6 years was 6.03 (95% CI = 4.85-7.58). The annual rate of RHS per 10,000 children ≤ 6 years increased (m = 0.200, ß = 0.802, p < 0.001) from 5.18 (95% CI 2.96-7.39) in 2004 to 7.69 (95% CI = 4.63-10.75) in 2018. The most common mechanism associated with RHS was falls (39.4%) with 103,466 (95% CI 74,806-132,125) cases. Pulls accounted for the second most common mechanism of injury, accounting for 90,146 (95% CI 68,274-112,018) cases or 36.2%. Yearly RHS incidence was compared to obesity prevalence for ages 2-5 children provided by the National Health and Nutritional Examination Survey (NHANES) surveys. Changes in obesity prevalence may visually reflect RHS incidence trends, but no causality between obesity prevalence and RHS incidence could be confirmed.

CONCLUSION

This study corroborated previous findings that falls and arm pulling contribute to the vast majority of RHS cases. The nonsignificant rise in RHS cases may reflect a possible plateau in obesity prevalence of children aged 2-5 years in recent years.

LEVEL OF EVIDENCE

III.

Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow

INTRODUCTION

Pulled elbow (PE) is one of the most common injury in children under the age of five years. Diagnosis of PE is usually based on the typical anamnesis and clinical symptoms. A simple reduction maneuver without the need of any imaging modality can eliminate the problem. Certain fractures however can mimic the physical findings of PE and in this cases reduction should not be attempted. The aim of our prospective diagnostic study was to evaluate the accuracy of a sonographic testing method in the differential diagnosis of PE.

METHODS

205 children aged 0-5 with clinical suspicion for PE were enrolled in our study. Inclusion criteria were the typical clinical sign of PE: painful, motionless, extended or slightly flexed and pronated arm following a traumatic event under the age of five. We excluded older children and patients with pronounced elbow swelling and initially flexed and supinated upper arm position. A two plane point of care sonographic examination was carried out at each patient immediately after history taking and primary physical survey. Presence of the elevated dorsal sonographic fat pad sign(FPS) and the synovial fringe enlargement (SFE) were examined from dorsal and ventral longitudinal planes. Children with FPS positivity and/or unsuccessful reduction were x-rayed. Suspected occult fractures with persistent complains were also x-rayed on the 3rd week. Sonographic pictures and x-rays were analyzed and compared to clinical findings.

RESULTS

The diagnosis of PE was confirmed in 196 cases. (95.6%). 9 children had type I. supracondylar humerus fractures. (4.39%) Out of these 2 proved to be occult fractures.(0.97%). SFE positivity was detected only in the PE group (156 cases, 76%) fractures have not shown this sign. Elevated FPS was negative in all but one PE cases, while all fractures showed FPS positivity without exception. Evaluating the two parameters together both sensitivity, specificity, negative and positive predictive value were 100%.

CONCLUSIONS

The two plane sonographic point of care method is an effective tool for confirming the diagnosis of PE and excluding the presence of fractures. It is an easy, standard and objective procedure which can be used as a fast diagnostic test before reduction attempts.

Suspected Radial Head Subluxation in Infants: The Need for Radiologic Evaluation

ABSTRACT

Radial head subluxation ("pulled elbow" or "nursemaid's elbow") is a common pediatric condition in children aged 1 to 4 years, although it is an uncommon finding in nonambulatory infants. It is a clinical diagnosis, and further investigations such as x-ray are not routinely done. We present a case series of 2 nonambulatory infants with forearm fractures that were initially diagnosed as radial head subluxation. Current literature supports the use of x-ray in children with atypical or unclear history prior to an attempted pulled elbow reduction. We suggest that this recommendation should be extended to all nonambulatory infants, given the unlikely diagnosis of radial head subluxation, and the necessity for early recognition of injuries that may be indicators of abuse.

Management and Outcomes of Children With Nursemaid's Elbow

STUDY OBJECTIVE

We identify the incidence and predictors of missed fracture and characterize patterns of radiography performance in children with a diagnosis of radial head subluxation in the emergency department (ED) setting.

METHODS

We queried the Pediatric Health Information System database for visits by children younger than 10 years and with a diagnosis of radial head subluxation at 1 of 45 pediatric EDs from 2010 to 2018. The frequency of radiography use was assessed overall and between hospitals. Multivariable logistic regression was used to evaluate associations between patient-level characteristics and the outcome of missed fracture (return visit for upper extremity fracture within 7 days of the index visit).

RESULTS

We identified 88,466 eligible visits; the median patient age was 2.1 years, 59% of visits were by female patients, and in visits in which laterality was noted, 60% of cases occurred in the left arm. Radiography was performed at 28.5% of visits; hospital rates of radiography performance ranged from 19.8% to 41.7%. Missed upper extremity fractures were observed in 247 cases (0.3% of the cohort). The odds of missed fracture were higher in children older than 6 years (adjusted odds ratio 2.32; 95% confidence interval 1.12 to 4.81), children who underwent radiography at the index visit (adjusted odds ratio 2.52; 95% confidence interval 1.84 to 3.43), and children receiving acetaminophen or ibuprofen (adjusted odds ratio 1.54; 95% confidence interval 1.15 to 2.06).

CONCLUSION

Radiographs were obtained for greater than one quarter of children presenting to a pediatric ED with radial head subluxation, with wide variation between hospitals. Missed fractures were rare. Future efforts should aim to reduce unnecessary radiography in this population.

The impact of COVID-19 on shoulder and elbow trauma in a skeletally immature population: an Italian survey

Background

The aim of this study was to evaluate the impact of COVID-19 on the shoulder and elbow trauma in a skeletally immature population in 30 days starting from March 8, 2020, the first day of restrictions in Italy, and to compare it with the same period of 2019.

Materials and methods

All the skeletally immature (younger than 18 years) patients managed in the emergency unit of our hospital between March 8, 2020, and April 8, 2020 (COVID-19 [C19] period), for a shoulder and elbow trauma were retrospectively included and compared with patients with similar ages admitted in the same period of 2019 (no COVID-19 period). Six categories of diagnosis were distinguished: (1) contusions, (2) no physeal fractures, (3) physeal fractures (Salter-Harris), (4) sprains/subluxations, (5) dislocations, and (6) others (tendinitis, wounds, low back pain, and joint inflammation). According to the mechanism of injury, we arbitrarily distinguished 5 subgroups: (1) accidental fall; (2) sport trauma; (3) accident at school; (4) high-energy trauma occurred by car, public transport, and pedestrian investment; and (5) fall from height.

Results

During the C19 period, the number of total accesses in our trauma center steeply decreased: two-thirds less. Regardless of the patient age, we performed 65% less first aid shoulder/elbow services. The number of skeletally immature patients treated at our trauma center for all types of injuries was 350 during the no COVID-19 period and 54 during the C19 period; therefore, the influx of pediatric patients during the C19 period decreased by 84.6%. Furthermore, during the C19 period, (1) there were no cases of fractures, physeal fractures, and dislocations of the shoulder; (2) there were no cases of contusion, physeal fractures, and dislocations of the elbow; and (3) we observed the absence of high-energy, sports, and school injuries; and (4) during the pandemic, shoulder and elbow injuries mainly occurred as a result of accidental fall at home.

Conclusions

The pandemic forced us to become aware of the ways and places where skeletally immature subjects report shoulder and elbow traumas; therefore, it would be desirable that more considerable attention be directed toward the prevention of injury in areas at risk.

Radial head subluxation in pediatric clinics and emergency departments in China

PURPOSE

To investigate the characteristics of the onset and treatment of radial head subluxation (RHS) in pediatric clinics and emergency departments.

METHODS

A retrospective study was performed on 11, 404 RHS cases in 9827 children who visited pediatric clinics and emergency departments from January 2015 to December 2018. The patients who with history of trauma and fracture of the affected limb were excluded. The following factors were examined: the mechanisms of RHS, the type of manual reduction, the attending physician's clinical background (emergency surgeon, junior pediatric orthopedic surgeon or senior pediatric orthopedic surgeon), and the epidemiological features (gender, age, climate and location) of the injury.

RESULTS

The mean age of the patients was 27.93 ± 17.94 months (range 0.93-214.53 months), with a peak incidence of 10.73-44.53 months. Approximately two-thirds of RHS cases occurred in cold weather from January to March and from September to December. Females accounted for 53.81% (n = 6137) of the cases, and left injuries were predominant (56.87%, n = 6485) in all cases. Mechanisms of injury were classified as "pull" (90.57%, n = 10, 339), "fall" (1.56%, n = 178), "hit" (0.75%, n = 86) and "unknown" (7.02%, n = 801). The overall success rate of manual reduction was 99.47%, and the success rate of reduction was higher for senior pediatric orthopedic surgeons than for emergency surgeons and junior pediatric orthopedic surgeons (p < 0.05). However, there was still a recurrence rate of 12.16% in the 9827 patients.

CONCLUSION

Younger children are predisposed to RHS, and there is a possibility of recurrence. Trained emergency doctors can handle it well, but it is essential to refer patients to specialists when manual reduction failed.

Nursemaid's Elbow Reduction

Nursemaid's elbow, also known as radial head subluxation, is a common childhood orthopedic injury that can easily be diagnosed and reduced by the advanced practice nurse. It is most common in children 1-4 years of age and typically occurs as the result of a pulling mechanism on an outstretched arm. This leads to subluxation of the radial head at the annular ligament. The child subsequently refuses to use the affected arm, leading the caregiver to present for evaluation. This article explores epidemiology, pathophysiology, clinical presentation, reduction techniques, and parent education.

The usefulness of ultrasound and the posterior fat pad sign in pulled elbow

INTRODUCTION

A pulled elbow is a common cause of acute elbow pain that is generally managed by a reduction maneuver without radiographic examination. However, children with atypical presentation with no history of abrupt longitudinal traction should undergo elbow imaging. This study aimed to investigate plain radiography findings and determine the usefulness of ultrasonography (US) in atypical pulled elbow.

MATERIALS AND METHODS

We retrospectively reviewed the medical records and images of 37 (22 males) consecutive patients with pulled elbow who presented with an atypical history or failed reduction between April 2015 and September 2018. Mean age at presentation was 4.34 years (range, 1.25-9.5 years). Of the 37 elbows, 20 were left elbows. The injury mechanism, incidence of the posterior fat pad sign on plain radiographs, and characteristic US findings, pre- and post- reduction, were investigated.

RESULTS

The original mechanisms of injury included slipping (n = 14), rolling over the arm (n = 7), vague history (n = 6), falling down (n = 6), abrupt longitudinal traction (n = 2), and direct injury (n = 2). On plain radiographs, six of the 37 elbows (16%) showed the posterior fat pad sign. Before the reduction, an entrapped supinator, a pathognomonic sign of pulled elbow, was identified on US in all cases. After reduction, the characteristic US findings showed a disentangled and swollen supinator (100%) and restored annular ligament (100%) in all successful cases. Although a click was not felt in three cases, the reductions were considered successful because the annular ligament was restored on US with free elbow motion.

CONCLUSION

Pulled elbow may be caused by atypical mechanisms of injury, such as slipping and rolling over the arm. Clinicians should be aware of the possibility of the posterior fat pad sign on plain radiographs of pulled elbow to prevent unnecessary immobilization. In such circumstances, US is a useful method for detecting an entrapped supinator and confirming adequate reduction via restoration of the annular ligament in children with atypical pulled elbow.

Reconsidering the "Classic" Clinical History Associated with Subluxations of the Radial Head

Introduction

The national burden of radial head subluxations in the United States (U.S.) population is poorly defined, and non-classical injury mechanisms have been increasingly reported in recent years. The purpose of this study is to report historical national estimates and demographic characteristics of patients presenting to U.S. emergency departments (ED) with subluxations of the radial head.

Methods

This cross-sectional, retrospective study analyzes the National Electronic Injury Surveillance System (NEISS) database (2001–2017) to identify patients ≤ 7 years of age presenting to U.S. EDs with subluxations of the radial head.

Results

Linear regression (R2 = 0.65; P < 0.01) demonstrated that the annual number of patients presenting to U.S. EDs with subluxations of the radial head increased significantly (P < 0.001) between 2001 (N=13,247; confidence interval [CI], 9,492–17,001) and 2010 (N=21,723; CI, 18,762–24,685), but did not change significantly between 2010 and 2017 (R2 < 0.01; P = 0.85). It also demonstrated that 51.0% (CI, 45.3%–56.6%) of injuries were either self-induced or spontaneous, whereas 36.8% (CI, 31.6%–42.0%) and 9.4% (CI, 8.0%–10.7%) were associated with parents/guardians or siblings, respectively. The majority of injuries occurred in patients who were the age of one (33.5%; CI, 32.1%–35.0%) and two (35.1%; CI, 33.7%–36.6%); females (57.8%; CI, 56.8%–58.9%) were more commonly injured than males.

Conclusion

Although the national burden of radial head subluxations may be less than previously reported, it still results in over 20,000 ED visits annually in the U.S. Given that over half of such injuries are actually self-induced or spontaneous, caretakers should be taught to recognize the clinical presentation of radial head subluxation, since the classically described history of a patient being lifted or pulled by the arm may simply have never occurred.

Not just another nursemaid's: an enigmatic paediatric humeral fracture

In the medical literature, the discussion of radial head subluxation (RHS) and nursemaid's elbow may highlight the ability to diagnose and treat the injured patient without obtaining imaging studies. This case reiterates the importance of a thorough physical examination and the use of appropriate imaging when point tenderness is exposed in the injured limb. With point tenderness to the arm, a child with a presumed RHS, otherwise known as nursemaid's elbow, should be evaluated using radiographic imaging to prevent additional potentially destructive physical manipulation of the patient's upper extremity.

Pulled elbow in children

Question Our practice is seeing children with relatively minor injuries to their elbows, with a history of "swinging" them when their hands are being held to cross the road. Nothing is usually found on a physical examination. I know that this is likely a "pulled elbow." Can we manage this in the clinic setting rather than sending the family to the emergency department? What would be the best course of action in the clinic setting?Answer Pulled elbow, also called nursemaid's elbow, is a radial head subluxation caused by axial traction or a sudden pull of the extended pronated arm, and it is a very common phenomenon. The practice of swinging children while holding their hands should be abandoned. In the case of pulled elbow, the child usually avoids moving the affected arm, holding it close to his or her body, without considerable pain, and no obvious swelling or deformity can be seen. While a fracture should be excluded, pulled elbow can usually be identified based on this presentation. The reduction procedure can easily be done in the office setting, with an 80% success rate and no complications. The hyperpronation maneuver (holding the elbow at 90° and then firmly pronating the wrist) to reduce pulled elbow has been found to be better than a supination-flexion maneuver (holding the elbow at 90° with one hand, supinating and flexing the elbow rapidly with the other) and should be exercised first. When 2 trials of reduction are unsuccessful, the child's arm should be splinted and the family should be sent for further evaluation.

Radial Head Subluxation: Possible Effective Factors on Time to Re-use the Affected Limb

Introduction

Radial head subluxation (RHS) is a common disorder in children. Although it is not accompanied by any important short- or long-term sequel, it could make the parents worried about.

Objective

The purpose of this study was to determine the possible effective factors that may influence time to use the affected limb.

Methods

This cross-sectional study was conducted prospectively during the years 2014 to 2016. All children under the age of 6 years who visited the emergency department (ED) and were diagnosed as having RHS were eligible. The patients' baseline information was recorded. After the reduction, the time until the affected arm use returned was recorded. The possible relationship between the baseline data and time to re-use the affected limb was assessed.

Results

During the study period, 112 children with a mean age of 30.18 ± 18.18 months were evaluated (53% male). Among the children who visited the ED during the first 4 hours and thereafter, 84% and 60%, respectively, re-used their limb in less than 10 minutes after reduction (p = 0.004). Also, 55% of children less than or equal to 24 months and 89% over the age of 24 months re-used the arm in 10 minutes (p < 0.001). The success rate of the first reduction maneuver was significantly lower in children with a recurrent dislocation (p = 0.001).

Conclusion

It is likely that age less than or equal to 24 months and ED visit after 4 hours of the event lead to a longer duration for re-using the affected arm following reduction.

Manipulative interventions for reducing pulled elbow in young children

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.

Radial Head Subluxation Among Young Children in the United States Associated With Consumer Products and Recreational Activities

This study investigated the epidemiology of children treated in US emergency departments for radial head subluxation (RHS) associated with consumer products and recreational activities using data from the National Electronic Injury Surveillance System. An estimated 430 766 (95% confidence interval: 341 194-520 339) children ≤5 years of age were treated for RHS in US emergency departments from 1990 to 2011. The mean patient age was 2.1 years, and 56.5% of patients were girls. The most common mechanism of injury was a fall (43.2%), followed by arm pull (39.4%). The annual rate of RHS increased significantly by 190.1% during the 22-year study period. This is the largest study of RHS to date and the first to use a nationally representative sample to investigate secular trends and mechanisms of injury for RHS associated with consumer products and recreational activities. Events associated with consumer products and recreational activities are an important increasing source of RHS.