Is hyperpronation superior to supination-flexion for radial head subluxation?

Hyperpronation achieves higher first-attempt reduction success than supination-flexion in young children, with similar pain and no additional harms—supporting hyperpronation as first-line.

Background

Radial head subluxation (nursemaid’s elbow) is a common injury in preschool-aged children. Although supination-flexion has been the traditional reduction technique, prior evidence (including a 2017 Cochrane review) suggested hyperpronation might be more effective, but most trials had high risk of bias. This systematic review and meta-analysis updates the evidence by incorporating both older and newer randomized controlled trials (RCTs).

Patients

  • Population: Children aged 0–6 years with clinically diagnosed radial head subluxation.
  • Setting: Primarily emergency departments; some orthopedic units.
  • Sample size: 11 RCTs, total n = 1,198 (median study size 115).

Intervention

Hyperpronation (forced pronation maneuver for reduction).

Control

Supination-flexion (forearm supination followed by elbow flexion).

Outcome

  • Primary outcome: Failure of the first reduction attempt.
  • Secondary outcomes: Pain during the maneuver; success after additional attempts (ultimate failure); short-term recurrence; adverse events.

Study Design

Systematic review and meta-analysis of RCTs (databases: PubMed, Embase, Web of Science; years 1980–2024; no language restriction). Risk of bias assessed with Cochrane ROB-2; certainty of evidence graded with GRADE. Fixed-effects meta-analysis used to pool risk ratios (RR) with 95% confidence intervals (CI).

Level of Evidence

  • Design-based: Level I (systematic review and meta-analysis of RCTs).
  • GRADE: Moderate certainty for the primary outcome.

Follow up period

  • Immediate procedural outcomes (first-attempt success/failure; subsequent attempts within 5–20 minutes).
  • Short-term recurrence assessed up to 72 hours in one low-risk RCT.

Results

Primary outcome: Failure of first reduction attempt

  • Pooled failure rates: Hyperpronation 9.42% vs Supination-flexion 25%.
  • Effect size: RR 0.38 (95% CI 0.29–0.50), favoring hyperpronation.
  • Absolute risk reduction (ARR): 15.58%.
  • NNT: 7 patients treated with hyperpronation to prevent one first-attempt failure (vs supination-flexion).

Secondary outcomes

  • Pain during maneuver: Across 8 studies, pain was generally similar between techniques; one study reported less pain with hyperpronation by subjective ratings. No consistent clinically meaningful difference.
  • Success after additional attempts / ultimate failure: Definitions and protocols varied (same-technique repeats vs crossover). Trends favored hyperpronation, but pooled analysis was not feasible. In the single low-risk RCT, ultimate failure was 8.2% (hyperpronation) vs 12.1% (supination-flexion); RR 0.68 (95% CI 0.23–2.02).
  • Recurrence within 72 hours: Reported in one low-risk RCT: 9.8% (hyperpronation, 6/61) vs 13.8% (supination-flexion, 8/58); RR 0.71 (95% CI 0.26–1.39). NNT: 25 to prevent one recurrence (imprecise; single study).
  • Adverse events: No treatment-related adverse events observed in the only study that systematically assessed them; most trials did not report harms.

Limitations

  • Predominance of high risk-of-bias trials (10 of 11), with issues including pseudo-randomization, inadequate allocation concealment, and lack of blinding.
  • Heterogeneous protocols for repeat attempts (same-technique vs crossover), variable definitions of ultimate failure, and inconsistent outcome timing.
  • Pain measured with different scales; selective or incomplete reporting across studies.
  • Harms and recurrence infrequently reported; limited data beyond immediate outcomes.
  • Moderate statistical heterogeneity for the primary outcome; however, no evidence of publication bias detected.

Funding

Not reported.

Citation

Aksel G, Çorbacıoğlu ŞK, Akoğlu H, İslam MM. Comparative effectiveness of supination-flexion and hyperpronation maneuvers in radial head subluxation: A systematic review and meta-analysis. American Journal of Emergency Medicine. 2025;92:68–78. doi:10.1016/j.ajem.2025.03.011.