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A literature-based algorithm for the treatment of children with radial head subluxation who fail to respond to initial hyperpronation
YAJEM-56521; No of Pages 2 American Journal of Emergency Medicine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
A literature-based algorithm for the treatment of children with radial head subluxation who fail to respond to initial hyperpronation Corby W. Makin, DO a, David R. Vinson, MD b,c,d,e,⁎ a
Department of Emergency Medicine, University of California Davis Health Systems, United States The Permanente Medical Group, Kaiser Permanente Division of Research, Oakland, CA, United States CREST Network, Oakland, CA, United States d Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, CA, United States e Volunteer Clinical Faculty, Department of Emergency Medicine, University of California Davis Health Systems, United States b c
a r t i c l e
i n f o
Article history: Received 18 February 2017 Accepted 1 March 2017 Available online xxxx
We are grateful to Bexkens et al. for their excellent systematic review of reduction maneuvers for radial head subluxation [1]. In demonstrating the superiority of hyperpronation (HP) compared to supination-flexion (SF) (90.8% vs 72.6%; Number Needed to Treat, 5.5), their study is sure to be of great help to practicing clinicians. Despite its excellent success rates, HP still fails to reduce a Nursemaid's elbow about 10% of the time. What then? Though Bexkens et al. did not address this question directly in their review, their identification of the trial literature on this topic set the stage for our review of these same trials with this question in mind: what sequence of steps does the literature suggest as a reasonable approach to the patient who fails to respond to initial HP? The systematic review included 701 patients from seven randomized control trials from 1998 to 2016 that compared HP to SF for first-attempt reduction success [1-8]. No uniform protocol was followed across these trials for what steps to take if the initial attempt was unsuccessful. The trials each had their own algorithm. We catalog these in Table 1. Variations are seen across the board, including the pre-procedural positioning of the elbow, the nature of the second maneuver (a repeat of the first, or a trial of the alternate procedure), the time interval between maneuvers (ranging from 10 min to 30 min), and the number of attempts undertaken before obtaining radiographs (ranging from three to four). Despite the lack of uniformity, some approaches were more commonly employed. Of the five trials that indicated the position of the
⁎ Corresponding author. E-mail addresses: [email protected] (C.W. Makin), [email protected] (D.R. Vinson).
elbow at the time of initial HP, four started with the elbow flexed between 70 and 90 degrees (Table 1). Six of the seven performed simple HP, whereas one followed HP immediately with flexion. Five of seven trials adopted HP as their second maneuver, whereas two switched to SF. The rates of success, however, were comparable: HP (16/25; 65%) vs SF (5/7; 71%). Of the six studies that reported a third maneuver, all switched to the technique that alternated with their second maneuver. Six trials reported the time intervals between procedures: three waited 10 min, two waited 15 min, and one observed their children for 30 min before the next attempt. Though one trial reported only the first two attempts and another specified a full four attempts, five of the seven prescribed three attempts before obtaining radiographs. Imaging was uncommonly needed, however, as most children achieved elbow reduction by the time of study completion (approximately 97%) (Table 1). If imaging was negative, children who failed to recover their normal active range of motion in most trials had their elbow immobilized and were provided close outpatient follow-up. Using this trial evidence as a guide to the treatment of children with presumed radial head subluxation, we propose the following approach. HP should be the initial maneuver with the elbow positioned between 70 and 90 degrees of flexion [1]. Up to three attempts can be pursued if needed, each separated by 10–15 min. Either HP or SF can be employed for the second maneuver, followed by the alternate for the third maneuver. Children who fail to regain normal elbow function after three reduction attempts should undergo radiographic evaluation. If the elbow x-rays are negative, it seems prudent to immobilize the arm and arrange close outpatient follow-up. Some children in these trials who had failed to respond to initial HP required a combination of maneuvers—HP plus SF—to finally achieve reduction. Though these trials separated the two maneuvers in time, we are curious about their performance in quick succession: HP followed immediately by SF as one integrated procedure. We have not seen this two-step combination subjected to formal study, but think it worth investigating. We summarize in Fig. 1 our approach to the child with presumed radial head subluxation. The suggestions beyond initial HP are not hard and fast, nor are they solidly evidence-based. But they are reasonable and emerge from the trial data as sensible steps to follow in the 10% of children whose Nursemaid's elbow needs something more than initial HP.
http://dx.doi.org/10.1016/j.ajem.2017.03.003 0735-6757/Published by Elsevier Inc.
Please cite this article as: Makin CW, Vinson DR, A literature-based algorithm for the treatment of children with radial head subluxation who fail to respond to initial hyperpronat..., American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.003
2
C.W. Makin, D.R. Vinson American Journal of Emergency Medicine xxx (2017) xxx–xxx
Table 1 Sequence of maneuvers and their success rates in trials of reduction techniques for presumed radial head subluxation. Trial's first author
Macias et al.b [2]
McDonald et al. [3] Green et al. [4] Bek et al. [5] Gunaydin et al. [6] Garcia-Mata and Hidalgo-Ovejero d [7]
Guzel et al.e [8]
Maneuver (elbow position)a [success n/total n] 1st attempt
2nd attempt
3rd attempt
4th attempt
HP (90°) [39/41]
HP (90°) [1/2]
Sup (90°), then flexion [0/1]
Sup (90°), then flexion [34/44] HP (NR), then flexion [53/67] Sup (NR), then flexion [47/68] HP (NR) [32/35] Sup (NR), then flexion [31/37] HP (90°) [32/34] Sup (90°), then flexion [22/32] HP (90°) [65/68] Sup (90°), then flexion [56/82] HP (70–90°) [61/65] Sup (90°) with simultaneous flexion [40/50] HP (NR) [36/40] Sup (NR), then flexion [25/38]
Sup (90°), then flexion [4/10] HP (NR), then flexion [9/14] Sup (NR), then flexion [4/21] Sup (NR), then flexion [3/3] HP (NR) [4/6] HP (90°) [2/2] Sup (90°), then flexion [7/10] HP (90°) [1/3] Sup (90°), then flexion [1/26] Sup (90°) with simultaneous flexion [2/4] HP (70–90°) [8/10]
HP (90°) [5/6] Sup (NR), then flexion [3/5] HP (NR), then flexion [13/17] Not needed NRc Not needed HP (90°) [3/3] Sup (90°), then flexion [2/2] HP (90°) [25/25] HP (70–90°) [1/2] Sup (90°) with simultaneous flexion [0/2] Sup (NR), then flexion [0/1] HP (NR) [0/6]
Sup (90°), then flexion [0/1] HP (90°) [1/1] – – – – – – – – – –
HP (NR) [3/4] Sup (NR), then flexion [7/13]
– –
HP, hyperpronation at the wrist; Sup, supination at the wrist; NR, not reported. a Elbow position at the time of maneuver is reported in degrees of flexion. b Five patients who failed to respond to the series of three maneuvers were found to have fractures. These are not included in this cohort of 85 patients. c The third maneuver was outside the study protocol and left to the discretion of treating physician. d Unlike the other trials, enrolled patients in this study may have failed repeat reduction attempts in other clinical settings before study enrollment. e Elbow position at time of maneuver is not specified in the text, but implied by a figure to be in only slight flexion.
References [1] Bexkens R, Washburn FJ, Eygendaal D, van den Bekerom MP, Oh LS. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: a systematic review and meta-analysis. Am J Emerg Med 2017;35(1):159–63. [2] Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics 1998;102(1):e10. [3] McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med 1999;6(7):715–8. [4] Green DA, Linares MY, Garcia Peña BM, Greenberg B, Baker RL. Randomized comparison of pain perception during radial head subluxation reduction using supinationflexion or forced pronation. Pediatr Emerg Care 2006;22(4):235–8. [5] 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):135–8. [6] Gunaydin YK, Katirci Y, Duymaz H, Vural K, Halhalli HC, Akcil M, et al. Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid's elbow cases. Am J Emerg Med 2013;31(7):1078–81. [7] García-Mata S, Hidalgo-Ovejero A. Efficacy of reduction maneuvers for “pulled elbow” in children: a prospective study of 115 cases. J Pediatr Orthop 2014;34(4):432–6. [8] Guzel M, Salt O, Demir MT, Akdemir HU, Durukan P, Yalcin A. Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation. Niger J Clin Pract 2014;17(2):201–4.
Fig. 1. An algorithmic approach to Nursemaid's elbow reduction derived from trial data. HP, hyperpronation; SF, supination with flexion. a. If SF was performed for the second maneuver, undertake HP for the third; and vice versa, if HP was performed for the second maneuver, undertake SF for the third.
Please cite this article as: Makin CW, Vinson DR, A literature-based algorithm for the treatment of children with radial head subluxation who fail to respond to initial hyperpronat..., American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.003
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
A literature-based algorithm for the treatment of children with radial head subluxation who fail to respond to initial hyperpronation Corby W. Makin, DO a, David R. Vinson, MD b,c,d,e,⁎ a
Department of Emergency Medicine, University of California Davis Health Systems, United States The Permanente Medical Group, Kaiser Permanente Division of Research, Oakland, CA, United States CREST Network, Oakland, CA, United States d Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, CA, United States e Volunteer Clinical Faculty, Department of Emergency Medicine, University of California Davis Health Systems, United States b c
a r t i c l e
i n f o
Article history: Received 18 February 2017 Accepted 1 March 2017 Available online xxxx
We are grateful to Bexkens et al. for their excellent systematic review of reduction maneuvers for radial head subluxation [1]. In demonstrating the superiority of hyperpronation (HP) compared to supination-flexion (SF) (90.8% vs 72.6%; Number Needed to Treat, 5.5), their study is sure to be of great help to practicing clinicians. Despite its excellent success rates, HP still fails to reduce a Nursemaid's elbow about 10% of the time. What then? Though Bexkens et al. did not address this question directly in their review, their identification of the trial literature on this topic set the stage for our review of these same trials with this question in mind: what sequence of steps does the literature suggest as a reasonable approach to the patient who fails to respond to initial HP? The systematic review included 701 patients from seven randomized control trials from 1998 to 2016 that compared HP to SF for first-attempt reduction success [1-8]. No uniform protocol was followed across these trials for what steps to take if the initial attempt was unsuccessful. The trials each had their own algorithm. We catalog these in Table 1. Variations are seen across the board, including the pre-procedural positioning of the elbow, the nature of the second maneuver (a repeat of the first, or a trial of the alternate procedure), the time interval between maneuvers (ranging from 10 min to 30 min), and the number of attempts undertaken before obtaining radiographs (ranging from three to four). Despite the lack of uniformity, some approaches were more commonly employed. Of the five trials that indicated the position of the
⁎ Corresponding author. E-mail addresses: [email protected] (C.W. Makin), [email protected] (D.R. Vinson).
elbow at the time of initial HP, four started with the elbow flexed between 70 and 90 degrees (Table 1). Six of the seven performed simple HP, whereas one followed HP immediately with flexion. Five of seven trials adopted HP as their second maneuver, whereas two switched to SF. The rates of success, however, were comparable: HP (16/25; 65%) vs SF (5/7; 71%). Of the six studies that reported a third maneuver, all switched to the technique that alternated with their second maneuver. Six trials reported the time intervals between procedures: three waited 10 min, two waited 15 min, and one observed their children for 30 min before the next attempt. Though one trial reported only the first two attempts and another specified a full four attempts, five of the seven prescribed three attempts before obtaining radiographs. Imaging was uncommonly needed, however, as most children achieved elbow reduction by the time of study completion (approximately 97%) (Table 1). If imaging was negative, children who failed to recover their normal active range of motion in most trials had their elbow immobilized and were provided close outpatient follow-up. Using this trial evidence as a guide to the treatment of children with presumed radial head subluxation, we propose the following approach. HP should be the initial maneuver with the elbow positioned between 70 and 90 degrees of flexion [1]. Up to three attempts can be pursued if needed, each separated by 10–15 min. Either HP or SF can be employed for the second maneuver, followed by the alternate for the third maneuver. Children who fail to regain normal elbow function after three reduction attempts should undergo radiographic evaluation. If the elbow x-rays are negative, it seems prudent to immobilize the arm and arrange close outpatient follow-up. Some children in these trials who had failed to respond to initial HP required a combination of maneuvers—HP plus SF—to finally achieve reduction. Though these trials separated the two maneuvers in time, we are curious about their performance in quick succession: HP followed immediately by SF as one integrated procedure. We have not seen this two-step combination subjected to formal study, but think it worth investigating. We summarize in Fig. 1 our approach to the child with presumed radial head subluxation. The suggestions beyond initial HP are not hard and fast, nor are they solidly evidence-based. But they are reasonable and emerge from the trial data as sensible steps to follow in the 10% of children whose Nursemaid's elbow needs something more than initial HP.
http://dx.doi.org/10.1016/j.ajem.2017.03.003 0735-6757/Published by Elsevier Inc.
Please cite this article as: Makin CW, Vinson DR, A literature-based algorithm for the treatment of children with radial head subluxation who fail to respond to initial hyperpronat..., American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.003
2
C.W. Makin, D.R. Vinson American Journal of Emergency Medicine xxx (2017) xxx–xxx
Table 1 Sequence of maneuvers and their success rates in trials of reduction techniques for presumed radial head subluxation. Trial's first author
Macias et al.b [2]
McDonald et al. [3] Green et al. [4] Bek et al. [5] Gunaydin et al. [6] Garcia-Mata and Hidalgo-Ovejero d [7]
Guzel et al.e [8]
Maneuver (elbow position)a [success n/total n] 1st attempt
2nd attempt
3rd attempt
4th attempt
HP (90°) [39/41]
HP (90°) [1/2]
Sup (90°), then flexion [0/1]
Sup (90°), then flexion [34/44] HP (NR), then flexion [53/67] Sup (NR), then flexion [47/68] HP (NR) [32/35] Sup (NR), then flexion [31/37] HP (90°) [32/34] Sup (90°), then flexion [22/32] HP (90°) [65/68] Sup (90°), then flexion [56/82] HP (70–90°) [61/65] Sup (90°) with simultaneous flexion [40/50] HP (NR) [36/40] Sup (NR), then flexion [25/38]
Sup (90°), then flexion [4/10] HP (NR), then flexion [9/14] Sup (NR), then flexion [4/21] Sup (NR), then flexion [3/3] HP (NR) [4/6] HP (90°) [2/2] Sup (90°), then flexion [7/10] HP (90°) [1/3] Sup (90°), then flexion [1/26] Sup (90°) with simultaneous flexion [2/4] HP (70–90°) [8/10]
HP (90°) [5/6] Sup (NR), then flexion [3/5] HP (NR), then flexion [13/17] Not needed NRc Not needed HP (90°) [3/3] Sup (90°), then flexion [2/2] HP (90°) [25/25] HP (70–90°) [1/2] Sup (90°) with simultaneous flexion [0/2] Sup (NR), then flexion [0/1] HP (NR) [0/6]
Sup (90°), then flexion [0/1] HP (90°) [1/1] – – – – – – – – – –
HP (NR) [3/4] Sup (NR), then flexion [7/13]
– –
HP, hyperpronation at the wrist; Sup, supination at the wrist; NR, not reported. a Elbow position at the time of maneuver is reported in degrees of flexion. b Five patients who failed to respond to the series of three maneuvers were found to have fractures. These are not included in this cohort of 85 patients. c The third maneuver was outside the study protocol and left to the discretion of treating physician. d Unlike the other trials, enrolled patients in this study may have failed repeat reduction attempts in other clinical settings before study enrollment. e Elbow position at time of maneuver is not specified in the text, but implied by a figure to be in only slight flexion.
References [1] Bexkens R, Washburn FJ, Eygendaal D, van den Bekerom MP, Oh LS. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: a systematic review and meta-analysis. Am J Emerg Med 2017;35(1):159–63. [2] Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics 1998;102(1):e10. [3] McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med 1999;6(7):715–8. [4] Green DA, Linares MY, Garcia Peña BM, Greenberg B, Baker RL. Randomized comparison of pain perception during radial head subluxation reduction using supinationflexion or forced pronation. Pediatr Emerg Care 2006;22(4):235–8. [5] 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):135–8. [6] Gunaydin YK, Katirci Y, Duymaz H, Vural K, Halhalli HC, Akcil M, et al. Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid's elbow cases. Am J Emerg Med 2013;31(7):1078–81. [7] García-Mata S, Hidalgo-Ovejero A. Efficacy of reduction maneuvers for “pulled elbow” in children: a prospective study of 115 cases. J Pediatr Orthop 2014;34(4):432–6. [8] Guzel M, Salt O, Demir MT, Akdemir HU, Durukan P, Yalcin A. Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation. Niger J Clin Pract 2014;17(2):201–4.
Fig. 1. An algorithmic approach to Nursemaid's elbow reduction derived from trial data. HP, hyperpronation; SF, supination with flexion. a. If SF was performed for the second maneuver, undertake HP for the third; and vice versa, if HP was performed for the second maneuver, undertake SF for the third.
Please cite this article as: Makin CW, Vinson DR, A literature-based algorithm for the treatment of children with radial head subluxation who fail to respond to initial hyperpronat..., American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.003