Pronation versus supination maneuvers for the reduction of radial head subluxation: A Meta-analysis

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1 Chinese Journal of Tissue Engineering Research August 3, 05 Vol.9, No.33 Meta ( 3007) Meta Meta Meta /(RCT) the Cochrane Central Register of Controlled Trials(CENTRAL) PubMed EMbase the ISI Web of Knowledge Database CNKI CMB VIP 05 3 Meta Cochrane Rev-Man Meta : [RR=.7 95%CI(.08.8) P= ] [RR=0.5 95%CI( ) P=0.005] [RR=.39 95%CI( ) P=0.30] GRADE RCT 99 :R38 :B :095-3 (05) Meta [J]. 05 9(33): doi:0.3969/j.issn Pronation versus supination maneuvers for the reduction of radial head subluxation: A Meta-analysis Feng Fan, Deng Zhou-ming, Ran Bing, Xie Yuan-long, Ruan Wen-feng, Cai Lin (Fourth Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 3007, Hubei Province, China) Abstract BACKGROUND: Supination maneuver is mainly used for reduction of radial head subluxation in children, but recently, pronation maneuver has also achieved good results in the treatment of radial head subluxation. OBJECTIVE: To objectively evaluate the efficacy of pronation versus supination maneuvers for the reduction of radial head subluxation by using Meta-analysis. METHODS: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMbase, the ISI Web of Knowledge databases, VIP, CNKI, CBM and Wanfang were searched from database establishment to December 0 for collecting the randomized controlled trials (RCTs) about pronation versus supination maneuvers for the reduction of radial head subluxation, and the references of those RCTs were also searched by hand. After study selection, assessment and data extraction were conducted by two reviewers independently. Meta-analyses were performed by using the RevMan 5. software. RESULTS AND CONCLUSION: Five studies involving 36 patients were included. The results of Meta-analyses showed that: compared with the supination maneuvers group the pronation maneuvers group had a higher rate of successful reduction at the first attempt [RR=.7, 95%CI (.08,.8), P= ] and lower rate of failed reduction [RR=0.5, 95%CI (0.09, 0.65), P=0.005]. There was no significant difference in the rate of successful Feng Fan, Studying for master s degree, Fourth Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 3007, Hubei Province, China Accepted: P.O. Box 000, Shenyang 080

2 . Meta reduction at the second attempt [RR=.39, 95%CI (0.75,.58), P=0.30]. Based on the results of systemic assessment, the level of evidence assessed by the GRADE system showed that the outcome indicators of the rate of successful reduction at the first attempt and rate of failed reduction were graded as intermediate level; the outcome indicator of the rate of successful reduction at the second attempt was graded as low level. For the poor quality of the original studies, a prudent choice is suggested; and more highly-quality, large-sample studies are needed. Subject headings: Radius; Dislocations; Pronation; Supination Feng F, Deng ZM, Ran B, Xie YL, Ruan WF, Cai L. Pronation versus supination maneuvers for the reduction of radial head subluxation: A Meta-analysis. Zhongguo Zuzhi Gongcheng Yanjiu. 05;9(33): Introduction (radial head subluxation RHS) [-] < 5 [3] 3 [-5] [6] [7] [5-6] [8-0] GRADE Data and methods. / (RCT) the Cochrane Central Register of Controlled Trials(CENTRAL) PubMed EMbase theisi Web of Knowledge Database CNKI CMB VIP05 3 PubMed # radial head subluxation OR RHS OR pulled elbow # pronationreduction OR hyperpronation reduction #3 supination reduction OR supination-flexion reduction # # and # and #3 CNKI # OR RHS OR # #3 # # and # and # Cochrane 5. [] RCT3 Low risk High riskunclear risk.3. GRADE [] ( A) ( B) ( C) ISSN CN -58/R CODEN: ZLKHAH 503

3 . Meta ( D) RCT RCT.5 MetaCochrane Rev-Man 5.3 I P 0. I 50% P < 0. I > 50% (Meta ) Meta (RR) (MD) (SMD) 95% (CI) GRADEpro 3.6 [3] 3 Results. RCT [-8] 36 Meta Table General information of included studies about pronation versus supination maneuvers for the reduction of radial head subluxation in children ( / n) ( ) Bek / 3/9 Green Guzel 0 0 9/ 38 9/9 Macias 998 5/6 9/5. Cochrane 5 ( 3) 5 McDonald [8] 3Green [5].3 Meta 5 (P=0.37 I =7%) McDonald / / (n=95) (n=5) (n=3) (n=5) (n=5) (n=0) (Meta )(n=5) (n=8) (n=9) Meta Figure Meta-analysis screening of literature about pronation versus supination maneuvers for the reduction of radial head subluxation in children 50 P.O. Box 000, Shenyang 080

4 . Meta Meta Figure Bias risk map of Meta-analysis of pronation versus supination maneuvers for the reduction of radial head subluxation in children 3 Meta Figure 3 Bias risk map of Meta-analysis of pronation versus supination maneuvers for the reduction of radial head subluxation in children Meta GRADE Table GRADE conclusive table of the Meta-analysis of pronation versus supination maneuvers for the reduction of radial head subluxation in children GRADE [n/n(%)] [n/n(%)] 5 RCT 93/7(88.9) 63/9(7.) RR=.7 95%CI (.08.8) RCT 5/0(75.0) /(50.0) RR=.39 95%CI ( ) 5 RCT /7(.8) /9(9.6) RR=0.5 95%CI ( ) ( ) [RR=.7 95%CI(.08.8) P= ] 5 5 (P=0.03 I =67%) [RR=.39 95%CI( ) P=0.30] 56 (P=0.88 I =0%) ( ) [RR=0.5 95%CI( ) P=0.005]. GRADE 3 GRADE 3 Discussion Meta 3.3 ISSN CN -58/R CODEN: ZLKHAH 505

5 . Meta Study or Subgroup Bek, D. 009 Green, D. A. 006 Guzel, M. 0 Macias, C. G.998 McDonald, J. 999 Risk Ratio Risk Ratio Weight.3%.0%.% 38.7% 6.9%.37 [.07,.75].09 [0.9,.30].37 [.06,.76].3 [0.99,.8]. [0.9,.0] (95% CI) % events Heterogeneity: Tau² = 0.00; Chi² =.30, df = (P = 0.37); I² = 7% Test for overall effect: Z = 3.66 (P = ).7 [.08,.8] Meta Figure Meta-analysis of the rate of successful reduction at the first attempt in pronation and supination maneuvers groups Study or Subgroup Bek, D. 009 Guzel, M. 0 Macias, C. G.998 McDonald, J. 999 Risk Ratio Risk Ratio Weight % 33.3% 9.7% 9.8%. [0.6,.3].00 [0.66,.5].7 [0., 3.08] 3.38 [.9, 8.85] (95% CI) events 5 Heterogeneity: Tau² = 0.5; Chi² = 9.0, df = 3 (P = 0.03); I² = 67% Test for overall effect: Z =.05 (P = 0.30) %.39 [0.75,.56] Meta Figure 5 Meta-analysis of the rate of successful reduction at the second attempt in pronation and supination maneuvers groups Study or Subgroup Bek, D. 009 Green, D. A. 006 Guzel, M. 0 Macias, C. G.998 McDonald, J. 999 Risk Ratio Risk Ratio Weight.% 0.5%.%.0% 3.% 0.3 [0.0,.5] 0. [0.0,.5] 0.6 [0.0,.5] 0.8 [0.0,.] 0.5 [0.0,.68] (95% CI) % events Heterogeneity: Tau² = 0.00; Chi² =.9, df = (P = 0.88); I² = 0% Test for overall effect: Z =.83 (P = 0.005) 0.5 [0.09, 0.65] Meta Figure 6 Meta-analysis of the rate of failed reduction in pronation and supination maneuvers groups GRADE GRADE RCT P.O. Box 000, Shenyang 080

6 . Meta GRADE ( ) Meta CONSORT [9] References [] Schutzman SA, Teach S.Upper-extremity impairment in young children.ann Emerg Med.995;6():7-79. [] Jongschaap HC, Youngson GG, Beattie TF. The epidemiology of radial head subluxation ('pulled elbow') in the Aberdeen city area.. Health Bull (Edinb).990;8():58-6. [3],.[M].7. :,008:75. [] Klock LE, Miller TD, Morris AH, et al.a comparative study of atropine sulfate and isoproterenol hydrochloride in chronic bronchitis.am Rev Respir Dis. 975;(3): [5],. [M].. :, 988:888. [6],,. : [M].. 0: 555. [7] Salter RB, Zaltz C. Anatomic investigations of the mechanism of injury and pathologic anatomy of "pulled elbow" in young children. Clin Orthop Relat Res.97;77:3-3. [8] Harley JR, Injuries of the upper extremities.//wiebe RA, Ahrens WR,Strange GR, et al, eds. Pediatric Emergency Medicine. 3rd ed. New York,NY: McGraw-Hill.009. [9] Courtney Hopkins-Mann, Damilola Ogunnaike-Joseph, Donna Moro-Sutherland.Pediatric procedures: nursemaids elbowreduction.// Tintinalli JE, Kelen GD,Stapczynski JS, eds. Tintinalli semergency Medicine: A ComprehensiveStudy Guide. 7th ed. New York, NY:McGraw-Hill. 0. [0] Potis T, Merrill H.Is pronation less painful and more effective than supination for reduction of a radial head subluxation? Ann Emerg Med.03;6(3): 9-9. [] Julian PT Higgins,Sally Green.Cochrane Handbook for SystematicReviews of Interventions Version 5..0 [updated Macch 0].The Cochrane Collaboration. The Cochrane Collaboration, 0. Available from 0. [],,,.GRADE [J]., 0,(9): [3] GRADEpro. [Computer program]. Version 3. for Windows. JanBrozek, Andrew Oxman, Holger Schünemann [] Bek D, Yildiz C, Köse O, et al.pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial. Eur J Emerg Med.009;6(3): [5] Green DA, Linares MY, Garcia Peña BM, et al.randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. Pediatr Emerg Care.006;(): [6] Guzel M, Salt O, Demir MT, et al.comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation. Niger J Clin Pract.0;7():0-0. [7] Macias CG, Bothner J, Wiebe R..A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics.998;0():e0. [8] McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med.999;6(7): [9] Schulz KF, Moher D, Altman DG. CONSORT 00 comments. Lancet.00;376(978):-3. ISSN CN -58/R CODEN: ZLKHAH 507