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The Case
Parents bring in their daughter because they pulled on her arm, and now she is not using it. They are thoroughly convinced that the child’s arm is either broken or dislocated. We all recognize this as radial head subluxation or “nursemaid’s elbow” and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? What if nothing happens? Is there an alternative technique to reducing a nursemaid’s elbow?

Hyperpronation Reduction Technique
A 2009 paper by Bek et al described a method of pronation instead of supination-flexion1. The proposed maneuver involves one hand holding the elbow at 90 degrees of flexion and the other hand holding the wrist. The wrist is then hyperpronated to complete the reduction.

Sixty-six patients were randomized to either a traditional supination reduction or the hyperpronation maneuver. If the initial attempt failed, a second attempt was performed. If the second attempt failed, then the alternate method was performed. The bottom-line result was that the hyperpronation technique was 94% successful on the first attempt, compared to supination-flexion at 69%. Furthermore, three patients failed the supination technique (first and second attempt) but were successfully reduced with hyperpronation on the first attempt. Hyperpronation was also subjectively rated as significantly easier than the supination-flexion by the practitioner.

There was also a 2009 Cochrane review comparing these two reduction techniques which summarized findings from three small studies totaling 313 participants who were all under the age of seven years old. Although the studies were flawed because of incomplete reporting and non-blinded methodologies, the hyperpronation technique seems to be more successful and less painful than the supination technique.

In 2013, Gunaydin et al3 prospectively compared the two techniques and found that 68% (56/82) of the supination group and 96% (65/68) of the hyperpronation group were successfully reduced after the first attempt, mirroring the findings by Bek et al. There was, however, no difference seen in pain levels.
We’ve been using hyperpronation for the past several years and love it. In our experience, the maneuver seems less traumatic for the child (and parent). Has anyone else tried it? We would love to hear your experiences!

References
1. Bek D, Yildiz C, Köse O, Sehirlioğlu A, Başbozkurt M. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial. Eur J Emerg Med. 2009 Jun;16(3):135-8. doi: 10.1097/MEJ.0b013e32831d796a.  PubMed PMID: 19262394.
2. Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD007759. doi: 10.1002/14651858.CD007759.pub2. Review. Update in: Cochrane Database Syst Rev. 2012;1:CD007759. PubMed PMID: 19821438.
3. Gunaydin YK, Katirci Y, Duymaz H, Vural K, Halhalli HC, Akcil M, Coskun F. Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid’s elbow cases. Am J Emerg Med. 2013 Jul;31(7):1078-81. doi: 10.1016/j.ajem.2013.04.006. Epub 2013 May 20. PubMed PMID: 23702058.

Fred Wu, MHS, PA-C  is the Lead Physician Assistant in the Department of Medicine at the Kaweah Delta Medical Center, CEP America.
Michelle Lin , MD is the Associate Professor of Emergeny Medicine at the University of California, San Francisco

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Editor’s Note:
One of the best features of ALiEM is their library of Paucis Verbis cards on select EM topics. Below is our second in a series.

Anaphylaxis
Simons FER. J Allergy Clin Immunol 2010;125:S161-81. Arnold JJ, Williams PM. Amer Fam Phys 2011; 84(10):1111-8.

Definition: A serious allergic reaction that is rapid in onset and might cause death

Mechanism: IgE-mediated immune reaction

Pearl: Hypotension is NOT required to diagnose anaphylaxis.

Triggers:
Almost any food, allergens, or medication can be a trigger
• Common culprits: Abx (esp beta-lactams), NSAIDs, peanuts, shellfish

Organ Involvement:
Skin 80-90%, Resp 70%, GI 45%, CV 45%, CNS 15%

Biphasic anaphylaxis pattern:
2nd flare may occur despite trigger removed (typically within 72 hours of onset)

Diagnostic Criteria
(Highly likely if 1 of 3 criteria fulfilled) per 2nd National Institute ofAllergy and ID/Food Allergy and Anaphylaxis Network
1. Acute onset (min-several hrs) with involvement of skin, mucosa, or both (eg. hives, pruritis, flushing, facial angioedema) AND at least 1 of following:
   A. Respiratory compromise (eg. SOB, wheezing, stridor, reduced PEF, hypoxemia)
   B. Reduced BP or associated sx of end-organ dysfunction (hypotonia, syncope, incontinence)
2. Two or more of following that occur rapidly after exposure to likely allergen:
   A. Involvement of skin-mucosal tissue (eg. hives, itch-flush, facial angioedema)
   B. Respiratory compromise (eg. SOB, wheezing, stridor, reduced PEF, hypoxemia)
   C. Reduced BP or associated dx (eg. hypotonia, syncope, incontinence)
   D. Persistent GI sx (eg. cramping abdominal pain, vomiting)
3. Reduced BP after exposure to known allergen
   A. Infants/children: Low SBP (age specific*) or >30% decrease in SBP
   B. Adults: SBP <90 mmHg or >30% decrease in person’s baseline
   * Low pediatric SBP definitions:
   Age 1 mo-1 yr: SBP < 70 mmHg
   Age 1 yr-10 yr: SBP < (70 mmHg + [2 x age])

ED Management
Supine position, ABC’s
   IM epinephrine STAT. Repeat every 5-15 min if refractory.
      0.3-0.5 mg for adults = 0.3-0.5 mL of 1:1000 concentration of epinephrine
      0.15 mg for pt wt <30 kg
      IM injection into lateral thigh – quickest absorption centrally
   IV fluids 2 liters
   H1 antagonist (eg. Benadryl)
   H2 antagonist (eg. Ranitidine)
   Glucocorticoids (eg. Methylprednisolone; may blunt biphasic response)
   Albuterol (beta-agonist) nebulizer for wheezing/ lower airway obstruction
   Consider: Glucagon 3.5-5 mg IV if refractory to epinephrine and on beta-blockers
   If discharging patient home after observation, prescribe epinephrine pen!
 

more on the web
This article was originally published on the blog Academic Life in Emergency Medicine
AcademicLifeinEM.com

 

Comments   

# Michael Michaud PA-C 2013-11-18 14:38
Have been using hyperpronation for the past 3 years without a single failed attempt to date currently. The only additional point I would add is I place my hand under the bent elbow and place my thumb over the radial head to add in reduction while hyperpronating.
Reply
# Hyperpronation works for meFrank Moore 2013-11-20 07:38
I have been using the hyperpronation technique for many years. It is very quick and almost always works. It is easy to teach parents as well.

I always place my left thumb over the radial head. I don't know if it helps the reduction, but I can usually feel a pop when the radial head reduces.

I pronate until the arm won't turn easily any more, then give a quick extra tweek and that is when it reduces
Reply
# DrPeter bonneville 2013-11-20 13:17
Use it all the time though with elbow in extension and works well. It minimizes movement of the elbow as they are often spontaneously in extension.
Reply
# Co-Director of EM TrainingMark Putland 2013-11-20 18:27
I hold the elbow in extension with one hand on the distal humerus and one at the wrist, then supinate and give an axial load along the radius (pushing the wrist axially toward the elbow without flexing the elbow). Never seems to fail either (including twice on my own son). I think there are many ways to skin this cat. Good to hear of another one though.
Reply
# Co-Director of Emergency Medicine Training, Bendigo HealthMark Putland 2013-11-20 18:31
I hold the elbow in extension, with one hand on the distal humerus and one at the wrist, supinate and then provide an axial load along the radius, (pushing the radius toward the elbow without flexing the elbow). Also seems to never fail. I think there are many ways to skin this cat. Good to hear of another one though.
Reply
# Co-DEMT Bendigo Health Mark Putland 2013-12-03 10:33
And then the day after writing the above I had one that just wouldn't go in. I used my way, I used the hyperpronation described above. AArgh, still not in. Then our physiotherapist put in, doing essentially the same thing but just pushing in hard on the lateral aspect of the radial head with his thumb, to push the radial head toward the ulna.
Good to be still learning things.
Reply

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