Manipulative interventions for reducing pulled elbow in young children

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

doi:10.1002/14651858.CD007759.pub4

Scolaris Content Display Scolaris Content Display

Contenido relacionado

Ir a:

Revisiones y protocolos relacionados
Respuestas clínicas Cochrane
Guías
Temas

Revisiones y protocolos relacionados

Respuestas clínicas Cochrane

Topics

Temas

Figure 1

Study flow diagram

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 2

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 3

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 4

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.1

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.2

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 2.1

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

Ir a la figura de la revisiónAbrir en una pestaña nueva

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)

Ir a la tabla de la revisión

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

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

Ir a la tabla de la revisión

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

Table 2. Sensitivity analyses: Pronation versus supination: treatment failure at first attempt

Ir a la tabla de la revisión

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

Table 3. Pronation versus supination trials: ultimate failure

Ir a la tabla de la revisión

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]

Comparison 1. Pronation versus supination

Ir a la tabla de la revisión

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

Comparison 2. Supination and extension versus supination then flexion

Ir a la tabla de la revisión

The Cochrane Library

Scolaris Language Selector Scolaris Language Selector

Idioma de la Revisión Cochrane

Idioma de la web

Scolaris Content Language Banner Portlet Scolaris Content Language Banner Portlet