A retrospective study was performed in 100 children
aged between two and 16 years, with a dorsally angulated stable
fracture of the distal radius or forearm, who were treated with
manipulation in the emergency department (ED) using intranasal diamorphine
and 50% oxygen and nitrous oxide. Pre- and post-manipulation radiographs,
the final radiographs and the clinical notes were reviewed. A successful
reduction was achieved in 90 fractures (90%) and only three children
(3%) required remanipulation and Kirschner wire fixation or internal
fixation. The use of Entonox and intranasal diamorphine is safe and effective
for the closed reduction of a stable paediatric fracture of the
distal radius and forearm in the ED. By facilitating discharge on the same day, there is a substantial
cost benefit to families and the NHS and we recommend this method. Take home message: Simple easily reducible fractures of the distal
radius and forearm in children can be successfully and safely treated
in the ED using this approach, thus avoiding theatre admission and
costly hospital stay. Cite this article:
Paediatric distal radial and forearm fractures account for 37.4% of all fractures in children. We present our 2.5-year results of a novel safe approach to the treatment of simple distal radial and diaphyseal fractures using intranasal diamorphine and entonox in a designated fracture reduction room in the emergency department. All simple fractures of the distal radius and forearm admitted to our ED between March 2012 and August 2014 that could be reduced using simple manipulation techniques were included in this study. These included angulated diaphyseal fractures of the forearm, angulated metaphyseal fractures of the distal radius and Salter Harris types I and II without significant shortening. All children included were given intranasal diamorphine as well as entonox. The orthopaedic registrar on call performed all reductions. 100 children had their distal radius or forearm fracture reduced in the emergency department using entonox and diamorphine analgesia and had a same day discharge. Average age was 10 years (range 2.20–16.37 years). No complications were reported regarding the use of the analgesia and all children and parents were pleased with their treatment not requiring a hospital admission. The mean initial dorsal angulation of all fracture types was 28.05° degrees (23.91–32.23 95% CI) which was reduced to 7.03° (5.11–8.95 95% CI) post manipulation. There were 9 cases lost to follow up. Two cases lost the initial reduction of the fracture on subsequent clinic follow up and underwent internal fixation in theatre. The use of entonox and intranasal diamorphine is a safe, effective treatment of providing adequate analgesia for children with distal radial and forearm fractures to allow manipulation of displaced dorsally angulated fractures in the emergency department. By facilitating a same day discharge, over £45,000 was saved using this safe method of treatment.
