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Eur J Emerg Med. 2009 Jun;16(3):135-8. doi: 10.1097/MEJ.0b013e32831d796a.

Pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial.

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  • 1Department of Orthopedics and Traumatology, Gülhane Military Medical Academy, Ankara, Turkey.



The purpose of this study was to compare the efficiency of the hyperpronation and supination-flexion maneuvers in the reduction of the pulled elbow.


Sixty-six patients with pulled elbow were randomized for reduction with either hyperpronation or supination-flexion maneuvers. When the first attempt failed, a second attempt was performed with the same reduction maneuver. After failure of the second attempt the reduction maneuver was changed to the alternate method. The success rate of the reductions and the subjective rating on the difficulty of the reduction by the physician were recorded and analyzed statistically.


Thirty-two of 34 patients (94%) in the hyperpronation group and 22 of 32 patients (69%) in the supination-flexion group were reduced at first attempt (P=0.007). Two patients in the hyperpronation group and seven patients in the supination-flexion group were reduced at the second attempt. Reduction rates were statistically similar (P=0.06). Three patients in the supination-flexion group had failed reduction at the second attempt and the reduction maneuver needed to be changed. They were successfully reduced with hyperpronation maneuver at the first attempt. Final success rate of the hyperpronation maneuver at the first attempt was statistically higher than the supination-flexion maneuver (P=0.004). Furthermore, the hyperpronation maneuver was rated significantly easier than the supination-flexion maneuver by physicians (P=0.003).


Although final reduction rates were similar, the hyperpronation maneuver was more efficient at the first attempt, easier for physicians and less painful for the children.

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