BEST EVIDENCE TOPIC REPORTS Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary

A short cut review was carried out to establish whether a pronation manoeuvre is better than a supination manoeuvre for first time reduction of pulled elbow. Altogether 57 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated. Clinical scenario A 2 year old child is brought into the emergency department by her parents. They tell you that she has not used her left arm since tripping over while holding her older sister’s hand. The child is holding her left arm flexed at the elbow and semi-prone. The diagnosis is clearly a pulled elbow. You have heard various colleagues arguing vehemently for pronation and supination manoeuvres, and wonder which is actually the best method for reduction? Three part question In [a patient with a pulled elbow] is [a pronation manoeuvre better than a supination manoeuvre] at achieving [reduction and return to function at the first attempt]? Search strategy Medline 1966–10/02 using the OVID interface. [exp Elbow OR exp Elbow joint OR elbow.mp] AND [exp adolescence OR exp child OR exp child of impaired parents OR exp child, abandoned OR exp child, exceptional OR exp child, hospitalized OR exp child, institutionalized OR exp child, preschool OR exp child, unwanted OR exp disabled children OR exp homeless youth OR exp infant OR exp only child OR child$.mp Or exp Pediatrics OR pediatric$.mp OR paediatric$.mp] AND [exp Dislocations OR dislocation.mp OR subluxation.mp] AND [exp Manipulation, orthopedic OR manipulation.mp OR exp Pronation OR pronation.mp OR exp Supination OR supination.mp] LIMIT to human AND English. Best evidence topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary or placed on the BestBETs web site. Each BET has been constructed in the four stages that have been described elsewhere. The BETs shown here together with those published previously and those currently under construction can be seen at http://www.bestbets.org Eight BETs are included in this issue of the journal. c Reduction of pulled elbows c Alternative treatments for neck sprain c Tetanus prophylaxis in supeficial corneal abrasions c Gastric lavage in tricyclic antidepressant overdose c Treatment of uncomplicated subungual haematoma c Use of sterile gloves in the treatment of simple wounds c Antibiotics in orbital floor fractures c Contraindications to thrombolysis in patients on coumarins K Mackway Jones, Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; [email protected] 1 Carley SD, Mackway-Jones K, Jones A, et al. Moving towards evidence-based emergency medicine: use of a structured critical appraisal journal club. J Accid Emerg Med 1998;15:220–2. 2 Mackway-Jones K, Carley SD, Morton RJ, et al. The best evidence topic report: a modified CAT for summarising the available evidence in emergency medicine. J Accid Emerg Med 1998;15:222–6. 3 Mackway-Jones K, Carley SD. bestbets.org: Odds on favourite for evidence in emergency medicine reaches the worldwide web. J Accid Emerg Med 2000;17:235–6.