Nurse Reduction of Pulled Elbow
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ClinicalTrials.gov Identifier: NCT00993954 |
Recruitment Status :
Completed
First Posted : October 14, 2009
Results First Posted : December 30, 2014
Last Update Posted : December 30, 2014
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Radial head subluxation, also known as pulled elbow or nursemaid's elbow, is one of the most common upper extremity injuries in young children and a common reason for an emergency department visit.1 The injury typically occurs when a forceful longitudinal traction is applied to an extended and pronated forearm.2 Children with radial head subluxation are usually easily recognized by their clinical presentation and rapidly treated by a simple reduction technique involving either hyperpronation or supination and flexion of the injured arm.3-7
Despite the relative ease of diagnosis and treatment, children with radial head subluxation often wait several hours in a pediatric emergency department for a reduction that takes only a few minutes.8 Such visits have direct health care costs and involve time and stress for the child and their family. While many factors are associated with parental and patient satisfaction in the emergency department, it appears that that early treatment or intervention and shorter waiting times correlate with patient and parent satisfaction.9,10 As well, patient satisfaction appears to be the same or better when emergency department care for minor injuries is provided by nurse practitioners compared to physicians.11-13 Increasingly nurse initiated treatments and the use of medical directives and clinical pathways are becoming a focus in providing health care.14-17 While radial head subluxation treatment is an appropriate area to consider management by emergency department nurses, no studies have examined their role in the management of this common injury. Our study's objective was to examine whether triage nurses, trained in the use of a medical directive that taught recognition and treatment of radial head subluxation, could successfully reduce radial head subluxation at a rate similar to physicians. Given the practical constraints at the time of emergency department triage, this study was designed as a cluster randomized trial where the unit of randomization was a day and the patients on any given day were assigned to the nurse or physician arm for the entire day.
Condition or disease | Intervention/treatment | Phase |
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Radial Head Subluxation | Procedure: Reduction of Radial Head Subluxation | Not Applicable |

Study Type : | Interventional (Clinical Trial) |
Actual Enrollment : | 245 participants |
Allocation: | Randomized |
Intervention Model: | Single Group Assignment |
Masking: | None (Open Label) |
Primary Purpose: | Treatment |
Official Title: | Reduction of Radial Head Subluxation in Children Via a Nurse Initiated Pathway: A Randomized Control Trial |
Study Start Date : | October 2009 |
Actual Primary Completion Date : | October 2010 |
Actual Study Completion Date : | October 2010 |
Arm | Intervention/treatment |
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Experimental: Nurse Reduction
Patients randomized to reduction by nurse.
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Procedure: Reduction of Radial Head Subluxation
Nurse group will use hyperpronation with extension for first attempt and supination and flexion for second attempt. Physician controls will use either method at their discretion |
Active Comparator: Physician Reduction
Patients randomized to treatment by Emergency Department Physician in traditional ED manner
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Procedure: Reduction of Radial Head Subluxation
Nurse group will use hyperpronation with extension for first attempt and supination and flexion for second attempt. Physician controls will use either method at their discretion |
- Proportion of Patients With Successful Reduction of Radial Head Subluxation by Nurse, Compared With Physician Controls [ Time Frame: 10-15 minutes post reduction attempt ]
- Time to Discharge From ED (Minutes) [ Time Frame: End of enrollment ]
- Proportion of Patients With Presentation Compatible With RHS, Have Reduction Attempted, Who Are Subsequently Diagnosed With Fracture. [ Time Frame: Every 3 months during enrollment ]
- Proportion of Patients With RHS Not Identified by Nurse Pathway. [ Time Frame: End of enrollment ]

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Ages Eligible for Study: | up to 6 Years (Child) |
Sexes Eligible for Study: | All |
Accepts Healthy Volunteers: | No |
Inclusion Criteria:
- Age up to 6 years
- Physical exam consistent with RHS which includes not using the affected limb, holding the elbow in extension or slight flexion, forearm in pronation, and patient is distressed only on elbow movement
- Injury within preceding 12 hours
Exclusion Criteria:
- Deformity of clavicle or arm
- Swelling of elbow or wrist
- Significant tenderness on palpation of arm
- Metabolic bone disease (i.e. osteogenesis imperfecta)
- Neuromuscular disorder that excludes adequate assessment (i.e. severe cerebral palsy)

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT00993954
Canada, Ontario | |
Childrens Hospital of Eastern Ontario | |
Ottawa, Ontario, Canada, K1H 8L1 |
Principal Investigator: | Andrew C Dixon, MD | University of Alberta | |
Study Director: | Amy Plint, MD | University of Ottawa | |
Study Director: | Martin Osmond, MD | University of Ottawa | |
Study Director: | Nick Barrowman, PhD | University of Ottawa |
Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: | Andrew Dixon, Assistant Professor, University of Alberta |
ClinicalTrials.gov Identifier: | NCT00993954 |
Other Study ID Numbers: |
08/29x |
First Posted: | October 14, 2009 Key Record Dates |
Results First Posted: | December 30, 2014 |
Last Update Posted: | December 30, 2014 |
Last Verified: | December 2014 |
Nurse Treatment Pulled Elbow |
Joint Dislocations Joint Diseases Musculoskeletal Diseases Wounds and Injuries |