Nursemaid’s Elbow: Pronation or Supination?


Synopsis: This study concludes that the pronation technique for reduction of radial head subluxation is a viable alternative to the classic supination method.

Source: McDonald J, et al. Acad Emerg Med 1999;6:715-718.

The ed of a tertiary care children’s hospital was the site for this prospective, randomized study. One hundred forty-eight patients younger than 7 years were enrolled and randomized to receive either rapid supination and flexion vs. rapid pronation and flexion for patients with a presumptive diagnosis of radial head subluxation. Failure after first attempt, defined as no resolution of spontaneous use of the affected arm within 30 minutes, led to repeating that maneuver; after two failures, the alternative method of reduction was attempted. Four-point ordinal pain scoring data were provided by both the parent and the physician performing the maneuver in an attempt to grade the discomfort associated with each method.

No significant difference was found between the two techniques on first attempt (69% success supination vs 79% success pronation, P = 0.19). In cases of unsuccessful reduction, however, repeat pronation was significantly more likely to result in success than was repeat supination (64% success vs 19% success, P = 0.009). The two methods were equally successful on the third (crossover) attempt. When the left arm was injured, the pronation technique was significantly more likely to be effective, but there was no difference when the right arm was affected. Physicians rated the pronation method to be significantly less painful on the first attempt only; parental perceptions of pain did not favor a method. McDonald and coworkers conclude that the pronation technique for reduction of radial head subluxation is a viable alternative to the classic supination method, highlighting both its effectiveness when the left arm is injured (reason unclear), and the perception by physicians that it may be less painful.

Comment by Richard A. Harrigan, MD, FAAEM, FACEP

This paper adds support to advocates of the pronation technique for reduction of nursemaid’s elbow, or radial head subluxation. This study did not find the statistical advantage found by Macias and colleagues.1

In their study, Macias et al found first-attempt pronation to be significantly more successful than first-attempt supination (success rate 95% vs 77%, respectively). Enrollment and exclusion criteria were similar for both studies. Advantages of the study by McDonald and associates include a larger sample size with a priori power calculations and an assessment of pain. Furthermore, an increase in the time of observation before a reduction attempt was judged to be unsuccessful to 30 minutes in the current study (vs 15 minutes in the study by Macias and colleagues) is attractive. The 15-minute time frame may be too brief; 30 minutes is consistent with the recommendations of others.2 (Dr. Harrigan is Assistant Professor of Medicine, Temple University School of Medicine, Acting Chief and Associate Research Director, Division of Emergency Medicine, Temple University Hospital, Philadelphia, PA.)


1. Macias CG, et al. Pediatrics 1998;102e10. URL:

2. McNamara R. Management of common dislocations. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 3rd ed. Philadelphia, Pa. WB Saunders; 1998:818-852.