Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis.
OBJECTIVE
Nursemaid's elbow usually occurs in young children when longitudinal traction is placed on the arm. Several manipulative maneuvers have been described, although, the most effective treatment technique is yet unclear. The aim of this systematic review and meta-analysis was to compare the two most commonly performed maneuvers (supination-flexion and hyperpronation) in the treatment of nursemaid's elbow.


METHODS
A literature search was performed in PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing supination-flexion and hyperpronation. Data were extracted and pooled independently by two authors. Methodological quality assessment of included studies was performed. Meta-analysis was performed using a fixed-effect model in case of homogeneity across studies, and using a random-effect model in case of heterogeneity. Heterogeneity was calculated with the χ2test and inconsistency in study effects across trials was quantified by I2values.


RESULTS
Seven randomized trials, including 701 patients (62% female), were included. A total of 350 patients were treated with the hyperpronation maneuver versus 351 patients who underwent the supination-flexion maneuver. Meta-analysis showed that hyperpronation was more effective than supination-flexion (risk ratio, 0.34; 95% confidence interval, 0.23 to 0.49; I2, 35%). The absolute risk difference between maneuvers was 26% in favor of hyperpronation, resulting in a number needed to treat of 4 patients. Trials lacked blinding of assessors and universal pain measures.


CONCLUSIONS
Hyperpronation was more effective in terms of success rate and seems to be less painful compared to the supination-flexion maneuver in children with nursemaid's elbow.
Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. Electronic address: rbexkens@mgh.harvard.edu.
Rens
R
Bexkens
Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA 02114, USA. Electronic address: frederic.washburn@gmail.com.
Frederic J
FJ
Washburn
Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands; Department of Orthopaedic Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. Electronic address: deygendaal@amphia.nl.
Denise
D
Eygendaal
Department of Orthopaedic Surgery, Shoulder and Elbow Unit, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands. Electronic address: bekerom@gmail.com.
Michel P J
MP
van den Bekerom
Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, 175 Cambridge Street, Boston, MA 02114, USA. Electronic address: loh@mgh.harvard.edu.
Luke S
LS
Oh
D002648:Child; D002675:Child, Preschool; D004551:Elbow Joint; D006801:Humans; D007223:Infant; D004204:Joint Dislocations / Q000628:therapy*; D008349:Manipulation, Orthopedic / Q000379:methods*; D011403:Pronation; D013484:Supination; D016896:Treatment Outcome
Hyperpronation; Nursemaid's elbow; Radial head subluxation; Reduction; Supination-flexion