We’ve all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents 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 elbow?

Trick of the Trade: Hyperpronation techniquepronation

A 2009 paper by Bek et al.1 describes a method of pronation instead of supination. 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 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. Bottom line…hyperpronation was 94% successful on the first attempt compared to supination-flexion at 69%. Three patients failed supination-flexion (first and second attempt) but were successfully reduced with hyperpronation on the first attempt. Hyperpronation was also subjectively rated as significantly easier then supination-flexion by the practitioner.

I’ve been using hyperpronation for the past several years and love it. The maneuver appears less traumatic on the child (and parent).

Has anyone else tried it? I’d love to hear your experiences!

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;16(3):135-138. [PubMed]
Fred Wu, MHS, PA-C

Fred Wu, MHS, PA-C

Lead PA
Department of Emergency Medicine
Kaweah Delta Medical Center (Visalia, CA)
Fred Wu, MHS, PA-C

Latest posts by Fred Wu, MHS, PA-C (see all)