56 Manipulation and reduction of paediatric forearm fractures using Es-ketamine in a paediatric emergency department - a 5 year study

Background

Forearm fractures are the most common paediatric injury presenting to A+E.^1,2 Literature supports safe and effective treatment of these injuries in A+E using a variety of sedation methods, including ketamine.^3,4 The Paediatric Orthopaedic Trauma Snapshot (POTS) study showed that only 35% of A+Es nationally allow manipulation of these injuries in the department.

Methods

A retrospective analysis was undertaken of all patients presenting with fractures of the forearm between January 2012 to December 2016 who were treated with reduction and manipulation in the Alder Hey A+E department using Es-ketamine. Pre and post manipulation radiographs were reviewed, and fracture angulation measured pre and post reduction.

Results

A total of 151 patients were included with an average age of 8.5 years. 3 Salter Harris Type I, 16 Salter Harris Type II, 54 metaphyseal fractures, 44 distal third diaphyseal, 31 middle third diaphyseal and 3 proximal third diaphyseal were noted. 3 patients were lost to follow up after initial post reduction films. 11 patients required operative intervention following initial reduction. At one week follow up a further 5 patients were deemed to be of an unacceptable position requiring definitive operative management. No fractures slipped beyond 1 st week post procedure. A successful reduction, with improvement in lateral angulation, was achieved in 90% (133/148) of patients. The average pre-reduction lateral angulation was 23.7 degrees, post reduction was 4.6 and at final review was 0.3 degrees. At final follow up average 32 days all patients had clinical and radiological union.

Discussion

Es-Ketamine has been established as a safe method of sedation in paediatrics. Es-Ketamine allows same day discharge thus improving patient journey and leading to about £63 000 savings annually.

Conclusions

With adequate and appropriate training, the majority of simple radius and ulna fractures can be reduced and definitively treated safely and effectively using Es-ketamine in the emergency department. This technique has significant benefits in terms of resource management and finance whilst maintaining optimum patient care.

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