Original article 135 Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial Dog ˘ an Bek, Cemil Yildiz, O ¨ zkan Ko ¨se, Ali S ¸ehirliog ˘ lu and Mustafa Ba ¸ sbozkurt Objectives The purpose of this study was to compare the efficiency of the hyperpronation and supination–flexion maneuvers in the reduction of the pulled elbow. Methods Sixty-six patients with pulled elbow were randomized for reduction with either hyperpronation or supination–flexion maneuvers. When the first attempt failed, a second attempt was performed with the same reduction maneuver. After failure of the second attempt the reduction maneuver was changed to the alternate method. The success rate of the reductions and the subjective rating on the difficulty of the reduction by the physician were recorded and analyzed statistically. Results Thirty-two of 34 patients (94%) in the hyperpronation group and 22 of 32 patients (69%) in the supination–flexion group were reduced at first attempt (P =0.007). Two patients in the hyperpronation group and seven patients in the supination–flexion group were reduced at the second attempt. Reduction rates were statistically similar (P = 0.06). Three patients in the supination–flexion group had failed reduction at the second attempt and the reduction maneuver needed to be changed. They were successfully reduced with hyperpronation maneuver at the first attempt. Final success rate of the hyperpronation maneuver at the first attempt was statistically higher than the supination– flexion maneuver (P = 0.004). Furthermore, the hyperpronation maneuver was rated significantly easier than the supination–flexion maneuver by physicians (P = 0.003). Conclusion Although final reduction rates were similar, the hyperpronation maneuver was more efficient at the first attempt, easier for physicians and less painful for the children. European Journal of Emergency Medicine 16:135–138  c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins. European Journal of Emergency Medicine 2009, 16:135–138 Keywords: nursemaid’s elbow, pulled elbow, radial head, subluxation, treatment Department of Orthopedics and Traumatology, Gu ¨ lhane Military Medical Academy, Ankara, Turkey Correspondence to O ¨ zkan Ko ¨se, MD, Gu ¨ lhane Askeri Tip Akademisi, Ortopedi ve Travmatoloji AD., Gn. Tevfik Sag ˘ lam cd. Etlik, Ankara, Turkey Tel: +90 312 304 55 36; fax: +90 312 304 55 00; e-mail: drozkankose@hotmail.com Received 29 April 2008 Accepted 4 October 2008 Introduction In children younger than 5 years of age, one of the most common upper extremity injuries presenting to the emergency department is pulled elbow (PE) [1,2]. This refers to the traumatic subluxation of the radial head from the annular ligament produced with a sudden axial traction to an extended arm, whereas the forearm is pronated, as when one lifts a child by the forearm or pulls the forearm of a resisting child [3]. Refusal to use the affected arm, pain with elbow movements, and sometimes an audible click at the time of injury are common complaints that lead the parents to the emergency room urgently. The child holds the elbow by the side in slight flexion with the forearm pronated. Passive flexion and extension of the elbow may be in normal range, but supination of the forearm is limited and voluntarily resisted. Children with PE are usually easily recognized by the typical history and the clinical presentation and complete relief of the symptoms immediately after the reduction satisfies both the parents and the physicians. The standard recommendation for reducing PE involves supination followed by the flexion of the elbow [4,5]. Another alternative reduction maneuver, hyperpronation (HP) followed by the flexion of the elbow, has been reported to be easier and efficient in several studies [6–9]. The purpose of this randomized clinical trial was to compare the efficiency of the HP and supination–flexion (SF) maneuvers for the reduction of PE. Materials and methods This prospective study was carried out in the A&E Department of our institution between January 2007 and November 2007. Patients younger than 5 years of age with a suggestive clinical presentation and history of PE were included. Patients with an earlier history of PE, marked deformity, local swelling and ecchymosis at elbow, and polytraumatized patients were excluded from the study. After a complete physical examination, the patients who met the study criteria were randomly assigned to one of the treatment groups. No radiographs were taken for the assessment. Children with an odd birthday were 0969-9546  c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/MEJ.0b013e32831d796a Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.