Manipulative interventions for reducing pulled elbow in young children

Abstract

BackgroundPulled 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. ObjectivesTo compare the effects (benefits and harms) of the different methods used to manipulate pulled elbow in young children. Search methodsWe 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 criteriaRandomised 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 analysisTwo review authors independently evaluated trials for inclusion, assessed risk of bias, and extracted data. We pooled data using a fixedeffect model. Main resultsOverall, 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. Manipulative interventions for reducing pulled elbow in young children (Review)

The Epidemiology and Treatment of Pulled Elbow in Pediatric Population

“…12 In most of the studies, girls have been found more affected than boys. 13,14 Similarly, in our study, most patients with pulled elbow occurred in female children 71.9%. It is not clear why it is common in female children.…”

Role of the supinator muscle in the pathophysiological mechanism of a pulled elbow

“…Several studies have compared both manoeuvres and showed that the hyperpronation manoeuvre is less painful 12 and has a higher success rate for reduction, 6 although their results remain inconclusive 13 …”

“…Several studies have compared both manoeuvres and showed that the hyperpronation manoeuvre is less painful 12 and has a higher success rate for reduction, 6 although their results remain inconclusive. 13 This can be explained as follows. The hyperpronation manoeuvre is a direct reduction way that pulls up the trapped supinator muscle and annular ligament from the joint.…”

Current views on radial head subluxation

“…По его данным, при применении гиперпронационного метода удельный вес неудач первой попытки репозиции варьировал от 4,4 до 20,6 % (средние показатели -9,2 %), а при использовании супинационнофлексионного -от 16,2 до 34,2 % (средние показатели -26,4 %). При гиперпронационном методе отмечен существенно более низкий удельный вес неудачных попыток репозиции (отношение рисков (ОР) -0,53 %; ДИ 0,32-0,87 %) [42]. В последнем из опубликованных рандомизированных контролируемых исследований, в которое вошли 116 пациентов и которое не было учтено в упомянутых выше обзорах, гиперпронационный метод также признан более эффективным, чем супинационно-флексионный: репозиция с первой попытки достигнута у 85 против 53 % пациентов, со второй попытки -у 50 против 28 % пациентов.…”