Krul Marjolein, van der Wouden Johannes C, van Suijlekom-Smit Lisette W A, Koes Bart W
Department of General Practice, ErasmusMedical Center, Rotterdam, Netherlands.
Cochrane Database Syst Rev. 2012 Jan 18;1(1):CD007759. doi: 10.1002/14651858.CD007759.pub3.
Pulled elbow (nursemaid's elbow) is a common injury in young children. It 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. 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 textbooks recommend supination of the forearm, as opposed to pronation and other approaches. It is unclear which manoeuvre is most successful. This is an update of a Cochrane review first published in 2009.
The objective of this review is to compare the effectiveness and painfulness of the different methods used to manipulate pulled elbow in young children.
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: July 2011.
Any 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.
Two review authors independently evaluated trials for inclusion and, for the included trials, independently assessed the risk of bias and extracted data.
One trial with 66 children was newly included in this update. Overall, four trials with 379 children, all younger than seven years old, were included. All four trials compared pronation versus supination. One trial was at high risk of selection bias because allocation was not concealed and all four trials were at high risk of detection bias due to the lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (21/177 versus 47/181, risk ratio 0.45; 95% confidence interval 0.28 to 0.73). Pain perception was reported by two trials but data were unavailable for pooling. Both studies concluded that the pronation technique was less painful than the supination technique.
AUTHORS' CONCLUSIONS: There is limited evidence from four small low-quality trials that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children. We recommend that a high quality randomised trial be performed to strengthen the evidence.
牵拉肘（保姆肘）是幼儿常见的一种损伤。它通常是由成人或较高的人突然牵拉手臂所致，这种牵拉会使桡骨穿过环状韧带，导致桡骨头半脱位（部分脱位）。患儿会感到患侧手臂突然剧痛并丧失功能。牵拉肘通常通过手法复位半脱位的桡骨头来治疗。可以采用多种手法。大多数教科书推荐前臂旋后，而不是旋前及其他方法。目前尚不清楚哪种手法最为成功。这是对2009年首次发表的Cochrane系统评价的更新。
本系统评价的目的是比较用于处理幼儿牵拉肘的不同方法的有效性和疼痛程度。
我们检索了Cochrane骨、关节与肌肉创伤组专业注册库、Cochrane对照试验中央注册库、MEDLINE、EMBASE、CINAHL、LILACS、PEDro、临床试验注册库以及文章的参考文献列表。最后一次检索日期：2011年7月。
纳入任何评估牵拉肘手法干预的随机或半随机对照临床试验。我们的主要结局是首次尝试失败，需要进一步治疗。
两位综述作者独立评估纳入试验，对于纳入的试验，独立评估偏倚风险并提取数据。
本次更新新纳入一项有66名儿童的试验。总体而言，纳入了四项有379名均小于7岁儿童的试验。所有四项试验均比较了旋前与旋后。一项试验存在选择偏倚的高风险，因为分配未隐藏，且由于缺乏评估者盲法，所有四项试验均存在检测偏倚的高风险。旋前导致的失败在统计学上显著低于旋后（21/177 对比 47/181，风险比0.45；95%置信区间0.28至0.73）。两项试验报告了疼痛感受，但数据无法合并。两项研究均得出结论，旋前技术比旋后技术疼痛程度更低。
四项小型低质量试验提供的证据有限，表明在处理幼儿牵拉肘时，旋前方法可能比旋后方法更有效且疼痛程度更低。我们建议开展高质量的随机试验以强化证据。
