BACKGROUND: Pulled elbow (nursemaid's elbow) is a common injury in young 
children. It often results from a sudden pull on the arm, usually by an adult or 
taller person, which pulls the radius through the annular ligament, resulting in 
subluxation (partial dislocation) of the radial head. It can also be caused by a 
fall or twist. The child experiences sudden acute pain and loss of function in 
the affected arm. Pulled elbow is usually treated by manual reduction of the 
subluxed radial head. Various manoeuvres can be applied; most commonly, 
supination of the forearm, often combined with flexion, and (hyper-)pronation. 
It is unclear which is most successful. This is an update of a Cochrane review 
first published in 2009 and last updated in 2011.
OBJECTIVES: To compare the effects (benefits and harms) of the different methods 
used to manipulate pulled elbow in young children.
SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group 
Specialised Register, the Cochrane Central Register of Controlled Trials, 
MEDLINE, Embase, CINAHL, LILACS, PEDro, clinical trial registers and reference 
lists of articles. Date of last search: September 2016.
SELECTION CRITERIA: Randomised or quasi-randomised controlled clinical trials 
evaluating manipulative interventions for pulled elbow were included. Our 
primary outcome was failure at the first attempt, necessitating further 
treatment.
DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated trials 
for inclusion, assessed risk of bias, and extracted data. We pooled data using a 
fixed-effect model.
MAIN RESULTS: Overall, nine trials with 906 children (all younger than seven 
years old and 58% of whom were female) were included, of which five trials were 
newly identified in this update. Eight trials were performed in emergency 
departments or ambulatory care centres, and one was performed in a tertiary 
paediatric orthopaedic unit. Four trials were conducted in the USA, three in 
Turkey, one in Iran, and one in Spain. Five trials were at high risk of 
selection bias because allocation was not concealed and all trials were at high 
risk of detection bias due to the lack of assessor blinding. Eight trials 
compared hyperpronation with supination-flexion. We found low-quality evidence 
that hyperpronation resulted in less failure at first attempt than 
supination-flexion (9.2% versus 26.4%, risk ratio (RR) 0.35; 95% confidence 
interval (CI) 0.25 to 0.50; 811 participants, 8 studies). Based on an 
illustrative risk of 268 failures at first attempt per 1000 children treated 
using supination-flexion, this amounted to 174 fewer failures per 1000 children 
treated using hyperpronation (95% CI 134 to 201 fewer). Based on risk 
differences data, we also estimated a number needed to treat of 6 (95% CI 5 to 
8); this means that six children would need to be treated with the 
hyperpronation method rather than the supination-flexion method to avoid one 
additional failure at the first attempt.The very low-quality evidence (from four 
studies) for pain during or after manipulation means that it is uncertain 
whether there is or is not a difference between pronation and 
supination-flexion. There was very low-quality evidence from six studies that 
repeat pronation may be more effective than repeat supination-flexion for the 
second attempt after initial failure. The remaining outcomes were either not 
reported (adverse effects, recurrence) or unsuitable for pooling (ultimate 
failure). Ultimate failure, reported for the overall population only because of 
the differences in the study protocols with respect to what to do after the 
first attempt failed, ranged from no ultimate failures in two studies to six 
failures (4.1% of 148 episodes) in one study.One trial compared 
supination-extension versus supination-flexion. It provided very low-quality 
evidence (downgraded three levels for very serious risk of bias and serious 
imprecision) of no clear difference in failure at first attempt between the two 
methods.
AUTHORS' CONCLUSIONS: There was low-quality evidence from eight small trials 
that the pronation method may be more effective at first attempt than the 
supination method for manipulating pulled elbow in young children. For other 
outcomes, no conclusions could be drawn either because of very low-quality 
evidence or the outcomes not being reported. We suggest that a high-quality 
randomised clinical trial comparing hyperpronation and supination-flexion is 
required to provide definitive evidence. We recommend that this is preceded by a 
survey among clinicians to establish the extent of clinical equipoise and to 
optimise the study design and recruitment.