An alternative approach utilizes hyperpronation with flexion to achieve reduction.
Some clinicians use this method as their primary means of reduction, whereas
others employ it if the supination–flexion technique fails. This approach may be
less painful, although any discomfort during a successful reduction maneuver
should be short lived. As shown in Figure 130.50B , gently grasp the patient’s
hand on the affected side as if to shake it, stabilize the elbow joint in some
flexion, and place pressure with a finger on the radial head. Gently distract the
elbow joint and hyperpronate by rotating the hand on the affected side medially.
As before, a “pop” should be felt with the finger that overlies the radial head.

ACKNOWLEDGMENTS
Jennifer L. Green, MS, CCLS, BSN, RN—assisted with Preparation and
Assessment of the Child and Positioning and Restraints.
Mary Frey, MSN, RN—assisted with Accessing Central Venous Catheters,
Nasogastric Tube Placement, and Catheterization of the Bladder.
Suggested Readings and Key References
Preparation and Assessment of the Child and Positioning and Restraints
Committee on Hospital Care and Child Life Council. Child life services.
Pediatrics 2014;133(5):e1471–e1478.
Dingeman RS, Mitchell EA, Meyer EC, et al. Parent presence during complex
invasive procedures and cardiopulmonary resuscitation: a systematic review of
the literature. Pediatrics 2007;120(4):842–854.
Eppich WJ, Arnold LD. Family member presence in the pediatric emergency
department. Curr Opin Pediatr 2003;15(3):294–298.
Farah MM, Thomas CA, Shaw KN. Evidence-based guidelines for family
presence in the resuscitation room: a step-by-step approach. Pediatr Emerg
Care 2007;23(8):587–591.
Sacchetti A, Paston C, Carraccio C. Family members do not disrupt care when
present during invasive procedures. Acad Emerg Med 2005;12:477–479.
Umbilical Artery Catheterization
Barrington KJ. Umbilical artery catheters in the newborn: effects of position of

the catheter tip. Cochrane Database Syst Rev 2000;(2):CD000505.
Lumbar Puncture
Amini A, Liu JK, Kan P, et al. Cerebrospinal fluid dissecting into spinal epidural
space after lumbar puncture causing cauda equina syndrome: review of


literature and illustrative case. Childs Nerv Syst 2006;22:1639–1641.
Baxter AL, Welch JC, Burke BL, et al. Pain position, and stylet styles: infant
lumbar puncture practices of pediatric emergency physicians. Pediatr Emerg
Care 2004;20:816–820.
Breakey VR, Pirie J, Goldman RD. Pediatric and emergency medicine residents’
attitudes and practices for analgesia and sedation during lumbar puncture in
pediatric patients. Pediatrics 2007;119:e631–e636.
Nigrovic LE, McQueen AS, Neumann MI. Lumbar puncture success rate is not
influenced by family-member presence. Pediatrics 2007;120:e377–e382.
Nasal Cauterization/Nasal Packing—Anterior and Posterior
Joseph J, Martinez-Devesa P, Bellorini J, et al. Tranexamic acid for patients with
nasal
haemorrhage
(epistaxis).
Cochrane
Database
Syst
Rev
2018;12:Cd004328.
Murray S, Mendez A, Hopkins A, et al. Management of persistent epistaxis using
floseal hemostatic matrix vs. traditional nasal packing: a prospective
randomized control trial. J Otolaryngol Head Neck Surg 2018;47:1–9.
Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med
J 2005;81:309–314.

Randall DA. Epistaxis packing. Practical pointers for nosebleed control. Postgrad
Med 2006;119:77–82.
Svider P, Arianpour K, Mutchnick S. Management of epistaxis in children and
adolescents. Pediatr Clin N Am 2018;65:607–621.
Removal of a Nasal Foreign Body
Gregori D, Salerni L, Scarinzi C, et al; ESFBI Study Group. Foreign bodies in the
nose causing complications and requiring hospitalization in children 0–14 age:
results from the European survey of foreign bodies injuries study. Rhinology
2008;46:28–33.
Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children.
Pediatr Emerg Care 2008;24:785–792.
Purohit M, Ray S, Wilson T, et al. The ‘parent’s kiss’: an effective way to remove
paediatric nasal foreign bodies. Ann R Coll Surg Engl 2008;90:420–422.
Reimplantation of Avulsed Tooth
Andersson L, Andreasen JO, Day P, et al. International Association of Dental
Traumatology guidelines for the management of traumatic dental injuries: 2.
Avulsion of permanent teeth. Dent Traumatol 2012;28:88–96.


Emerich K, Wyszkowski J. Clinical practice: dental trauma. Eur J Pediatr
2010;169:1045–1050.
Keels MA, Section on Oral Health, American Academy of Pediatrics.
Management of dental trauma in a primary care setting. Pediatrics
2014;133:e466–e476.
Insertion of a Chest Tube
Dev SP, Nascimiento B Jr, Simone C, et al. Videos in clinical medicine. Chesttube insertion. N Engl J Med 2007;357:e15.
Replacement of a Gastrostomy Tube
Burke DR, El Shami A, Heinle E, et al. Comparison of gastrostomy tube
replacement verification using air insufflation versus gastrograffin. Arch Phys
Med Rehabil 2006;87:1530–1533.

Wu TS, Leech SJ, Rosenberg M, et al. Ultrasound can accurately guide
gastrostomy tube replacement and confirm proper tube placement at the
bedside. J Emerg Med 2009;36:280–284.
Reduction of an Incarcerated Inguinal Hernia
Goldman RD, Balasubramanian S, Wales P, et al. Pediatric surgeons and pediatric
emergency physicians’ attitudes towards analgesia and sedation for
incarcerated inguinal hernia reduction. J Pain 2005;6:650–655.
Niedzielski J, Kr IR, Gawlowska A. Could incarceration of inguinal hernia in
children be prevented? Med Sci Monit 2003;9:CR16–CR18.
Rectal Prolapse
Antao B, Bradley V, Roberts JP, et al. Management of rectal prolapse in children.
Dis Colon Rectum 2005;48:1620–1625.
Incision and Drainage of an Abscess
Aprahamian CJ, Nashad HH, DiSomma NM, et al. Treatment of subcutaneous
abscesses in children with incision and loop drainage: a simplified method of
care. J Pediatr Surg 2017;52:1438–1441.
Duong M, Markwell S, Peter J, et al. Randomized, controlled trial of antibiotics
in the management of community-acquired skin abscesses in the pediatric
patient. Ann Emerg Med 2010;55:401–407.
Hast MB, Klasner A, Kness S, et al. Cutaneous community-associated
methicillin-resistant staphylococcal aureus among all skin and soft-tissue


infections in two geographically distant pediatric emergency departments.
Acad Emerg Med 2007;14:35–40.
Ladde JG, Baker S, Rodgers CN, et al. The LOOP technique: a novel incision and
drainage technique in the treatment of skin abscesses in a pediatric ED. Am J
Emerg Med 2015;33:271–276.
McNamara WF, Hartin CW, Escobar MA, et al. An alternative to open incision
and drainage for community-acquired soft tissue abscesses in children. J

Pediatr Surg 2011;46:502–506.
Shoulder (Glenohumeral) Joint
Itoi E, Hatakeyama Y, Kido T, et al. A new method of immobilization after
traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder
Elbow Surg 2003;12:413–415.
Miller BS, Sonnabend DH, Hatrick C, et al. Should acute anterior dislocations of
the shoulder be immobilized in external rotation? A cadaveric study. J
Shoulder Elbow Surg 2004;13:589–592.
Tannebaum RD, Kondabala RK, Stockmal PJ. Postreduction radiographs for
anterior shoulder dislocation: a reappraisal. Ann Emerg Med 2001;37:418–419.
Patella
Saunders TG, Paruchuri NB, Zlatkin MB. MRI of osteochondral defects of the
lateral femoral condyle: incidence and pattern of injury after transient lateral
dislocation of the patella. AJR Am J Roentgenol 2006;187:1332–1337.
Zaida A, Babyn P, Astori I, et al. MRI of traumatic dislocations in children.
Pediatr Radiol 2006;36:1163–1170.
Elbow
Kuhn MA, Ross G. Acute elbow dislocations. Orthop Clin North Am
2008;39:155–161.
Mehta JA, Bain GI. Elbow dislocations in adults and children. Clin Sports Med
2004;23:609–627.
Sheps DM, Hildebrand KA, Boorman RS. Simple dislocations of the elbow:
evaluation and treatment. Hand Clin 2004;20:389–404.
Ingrown Toenail Repair
Daniel CR 3rd, Iorizzo M, Tosti A, et al. Ingrown toenails. Cutis 2006;78:407–
408.
Eekhof JA, Van Wijk B, Knuistingh Neven A, et al. Interventions for ingrowing
toenails. Cochrane Database Syst Rev 2012(4):CD001541.