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Cochrane Database of Systematic Reviews

Manipulative interventions for reducing pulled elbow in young children

Information

DOI:
https://doi.org/10.1002/14651858.CD007759.pub4Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 28 July 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Bone, Joint and Muscle Trauma Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Marjolein Krul

    Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands

  • Johannes C van der Wouden

    Correspondence to: Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, Netherlands

    [email protected]

  • Emma J Kruithof

    Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, Netherlands

  • Lisette WA van Suijlekom‐Smit

    Department of Paediatrics, Paediatric Rheumatology, Erasmus Medical Center ‐ Sophia Children's Hospital, Rotterdam, Netherlands

  • Bart W Koes

    Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands

Contributions of authors

Marjolein Krul

Drafting the protocol; searching the literature; inclusion procedure; data extraction and assessing risk of bias; drafting the text of the first published version of the review.

Johannes C van der Wouden

Contact author: providing general advice on the protocol and review; methodological advice; inclusion procedure; data extraction and assessing risk of bias. Drafting the text of the 2017 update.

Emma J Kruithof

Inclusion, data extraction and risk of bias assessment for the 2017 update. Interpreted results and assisted in drafting text.

Lisette WA van Suijlekom‐Smit

Providing general advice on the protocol and review.

Bart W Koes

Providing general advice on the protocol and review.

Sources of support

Internal sources

  • Department of General Practice, Erasmus MC, Netherlands.

  • Department of General Practice and Elderly Care Medicine, Amsterdam Public Health research institute, VUmc University Medical Center Amsterdam, Netherlands.

External sources

  • No sources of support supplied

Declarations of interest

None known.

Acknowledgements

We are grateful to Meisam Abdar for his translation of Asadi 2011 and to Serafín García‐Mata for providing details of the design of their study (Garcia‐Mata 2014).

The authors would like to acknowledge valuable comments at protocol and review stages from: Karen Black, Lesley Gillespie, Helen Handoll, Brian Rowe, Cathie Sherrington, Sue Stephen, Ben Vandemeer and Janet Wale. We particularly thank Joanne Elliott for her help with the search strategy and Lindsey Elstub for her help during editorial processing. We thank Ella Curtis for providing her paper.

This project was supported by the National Institute for Health Research via Cochrane Infrastructure funding to the Cochrane Bone, Joint and Muscle Trauma Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

Version history

Published

Title

Stage

Authors

Version

2017 Jul 28

Manipulative interventions for reducing pulled elbow in young children

Review

Marjolein Krul, Johannes C van der Wouden, Emma J Kruithof, Lisette WA van Suijlekom‐Smit, Bart W Koes

https://doi.org/10.1002/14651858.CD007759.pub4

2012 Jan 18

Manipulative interventions for reducing pulled elbow in young children

Review

Marjolein Krul, Johannes C van der Wouden, Lisette WA van Suijlekom‐Smit, Bart W Koes

https://doi.org/10.1002/14651858.CD007759.pub3

2009 Oct 07

Manipulative interventions for reducing pulled elbow in young children

Review

Marjolein Krul, Johannes C van der Wouden, Lisette WA van Suijlekom‐Smit, Bart W Koes

https://doi.org/10.1002/14651858.CD007759.pub2

2009 Jul 08

Manipulative interventions for reducing pulled elbow in young children

Protocol

Marjolein Krul, Johannes C van der Wouden, Lisette WA van Suijlekom‐Smit, Bart W Koes

https://doi.org/10.1002/14651858.CD007759

Differences between protocol and review

We had not anticipated that attempts for reducing the pulled elbow could have been made before the child entered into the study. We found one study where this was reported to be the case in 15% of the participants, a study performed in a tertiary paediatric orthopaedic unit (Garcia‐Mata 2014). We decided to include all children in the analysis, and perform a sensitivity analysis without the inclusion of the data from the 15%.

We added continued failure after a second attempt using the same initial procedure as an additional secondary outcome.

We also used Google to search for studies (October 2016) and found one study from Iran which was included for this update (Asadi 2011).

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram
Figures and Tables -
Figure 1

Study flow diagram

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Figures and Tables -
Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Figures and Tables -
Figure 3

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

Forest plot of comparison: 1 Pronation versus supination, outcome: 1.1 Failure: second attempt required.
Figures and Tables -
Figure 4

Forest plot of comparison: 1 Pronation versus supination, outcome: 1.1 Failure: second attempt required.

Comparison 1 Pronation versus supination, Outcome 1 Failure: second attempt required.
Figures and Tables -
Analysis 1.1

Comparison 1 Pronation versus supination, Outcome 1 Failure: second attempt required.

Comparison 1 Pronation versus supination, Outcome 2 Failure: continued failure after second attempt with same procedure.
Figures and Tables -
Analysis 1.2

Comparison 1 Pronation versus supination, Outcome 2 Failure: continued failure after second attempt with same procedure.

Comparison 2 Supination and extension versus supination then flexion, Outcome 1 Failure: second attempt required.
Figures and Tables -
Analysis 2.1

Comparison 2 Supination and extension versus supination then flexion, Outcome 1 Failure: second attempt required.

Pronation compared with supination reduction techniques for pulled elbow in young children

Patient or population: Children with pulled elbow1

Settings: Emergency departments, ambulatory care centres or orthopaedic units

Intervention: Pronation (all were hyperpronation) for first manipulation

Comparison: Supination (all included flexion) for first manipulation

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Supination‐flexion

Hyperpronation

Failure: second attempt required

268 per 10002

94 per 1000

(67 to 134)

RR 0.35

(0.25 to 0.50)

811
(8 studies)

⊕⊕⊝⊝
low3

Pain (preferably during the procedure)

see Comments

see Comments

see Comments

⊕⊝⊝⊝
very low4

Data for this outcome are incomplete and were measured in very different ways in four studies.

Adverse effects (e.g. bruising)

see Comments

see Comments

None of the trials reported this outcome.

Failure: continued failure after second attempt using same procedure as before

147 per 10002

24 per 1000
(14 to 47)

RR 0.16 (0.09 to 0.32)

624
(6 studies)

⊕⊝⊝⊝
very low5

This outcome represented the cumulative effect of two manipulations using hyperpronation versus cumulative effect of two manipulations using supination‐flexion. Reassuringly, both procedures when used again resulted in further successful reductions; these were proportionally greater with hyperpronation (64% versus 28%). However, the second attempt should not be considered independently of the first attempt and the characteristics of the children requiring a second attempt may have differed in important ways between the two groups.

Ultimate failure

see Comments

see Comments

Although potentially influenced by the initial (allocated) method of manipulation, this outcome reflected various manipulation protocols that stipulated the choice of method used for subsequent attempts. Overall failure at the end of the protocol ranged from 0 to 6 (4.1% of 148 episodes).

Recurrence (within one month)

see Comments

see Comments

None of the trials reported this outcome.

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk Ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1. Young children: typically aged under 7 years; mean age around 2 years.

2. Median control group (supination‐flexion) risk across studies

3. Evidence downgraded two levels for very serious risk of bias (selection and detection biases).

4. Evidence downgraded two levels for very serious risk of bias (selection, detection and incomplete outcome biases) and one level for inconsistency (two of the studies reported in favour of pronation, whereas two studies reported no difference between the procedures)

5. Evidence downgraded two levels for very serious risk of bias (and one level for imprecision (there were just 9 events in the hyperpronation group)

Figures and Tables -
Table 1. Synonyms for 'pulled elbow' found in the literature (adapted from Krul 2011)

Radial head subluxation

Partial dislocation of the radial head peculiar to children

Dislocation of the head of the radius by elongation

Annular ligament displacement

Partial epiphyseal separation of the radial head

Anterior isolated subluxation of the radial head

Internal derangement of the elbow

Slipped elbow of young children

Painful elongation of young children

Painful paralysis in young children

Rotation syndrome

Painful pronation

Tamper tantrum elbow

Elbow sprain

Goyrands’s injury

Malaigne’s luxation

Gromeyer’s injury

Pronatio dolorosa infantum (Chassaignac)

Curbstone fracture

Supermarket elbow

Sunday (afternoon) arm

Housemaid’s elbow

Nursemaid’s elbow

Babysitter’s elbow

Figures and Tables -
Table 1. Synonyms for 'pulled elbow' found in the literature (adapted from Krul 2011)
Table 2. Sensitivity analyses: Pronation versus supination: treatment failure at first attempt

Sensitivity analysis

Results

NNT

Removal of quasi‐RCTs

Asadi 2011; Bek 2009; Garcia‐Mata 2014 ; Gunaydin 2013

RR 0.47, 95% CI 0.30 to 0.73; 370 participants; I2 = 13%

8, 95% CI 5 to 17

Removal of Green 2006

(baseline imbalance)

RR 0.34, 95% CI 0.24 to 0.49; 739 participants; I2 = 35%

6, 95% CI 5 to 8

Removal of 17 participants with prior

manipulation in Garcia‐Mata 2014)

RR 0.35, 95% CI 0.24 to 0.50; 794 participants; I2 = 28%

7, 95% CI 5 to 10

Figures and Tables -
Table 2. Sensitivity analyses: Pronation versus supination: treatment failure at first attempt
Table 3. Pronation versus supination trials: ultimate failure

Study

Outcome definition

Overall no. of failures / no. episodes

Protocol

Asadi 2011

Failure after 4 attempts

Not reported

4 attempts,

cross‐over on 3rd attempt

Bek 2009

Failure after 3 attempts

0 / 66 (0%)

3 attempts,

cross‐over on 3rd attempt

Garcia‐Mata 2014

Failure after 3 attempts

3 / 115 (2.6%)

3 attempts,

cross‐over on 2rd attempt

original method for 3rd attempt

Green 2006

Failure after 2 attempts

2 / 75 (2.7%)

2 attempts,

cross‐over on 2nd attempt

Gunaydin 2013

Failure after 3 attempts

0 / 150 (0%)

3 attempts,

cross‐over on 3rd attempt

Guzel 2014

Failure after 3 attempts

Not reported

3 attempts,

cross‐over on 3rd attempt

Macias 1998

Failure after 4 attempts

1 / 90 (1.1%)

4 attempts,

cross‐over on 3rd attempt

order same for 4th attempt

McDonald 1999

Failure after 3 attempts

6 / 148 (4.1%)

3 attempts,

cross‐over on 3rd attempt

Figures and Tables -
Table 3. Pronation versus supination trials: ultimate failure
Comparison 1. Pronation versus supination

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Failure: second attempt required Show forest plot

8

811

Risk Ratio (M‐H, Fixed, 95% CI)

0.35 [0.25, 0.50]

2 Failure: continued failure after second attempt with same procedure Show forest plot

6

624

Risk Ratio (M‐H, Fixed, 95% CI)

0.16 [0.09, 0.32]

Figures and Tables -
Comparison 1. Pronation versus supination
Comparison 2. Supination and extension versus supination then flexion

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Failure: second attempt required Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 2. Supination and extension versus supination then flexion