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Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review
  1. Amelia Xin Chun Goh1,
  2. Jun Wei Yeo1,
  3. Jocelyn Fangjiao Gao1,
  4. Marcus Eng Hock Ong2,3,
  5. Shu-Ling Chong4,
  6. Fahad Javaid Siddiqui5,
  7. Andrew Fu Wah Ho2,5
  1. 1Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  2. 2Department of Emergency Medicine, Singapore General Hospital, Singapore
  3. 3Health Services & Systems Research, Duke-NUS Medical School, Singapore
  4. 4Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
  5. 5Pre-Hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
  1. Correspondence to Amelia Xin Chun Goh, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; gxcamelia{at}gmail.com

Abstract

Background Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method.

Methods MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use.

Results 1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA.

Conclusion Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.

  • fractures and dislocations
  • anaesthesia
  • emergency department
  • analgesia

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Footnotes

  • Handling editor David Metcalfe

  • Contributors AXCG conceptualised and developed the study protocol, led the article screening, data extraction, quality assessment and evidence synthesis and prepared the manuscript. JWY developed the initial concept and search strategy for the study, contributed to development of the protocol and article screening, extracted data, carried out quality assessment and reviewed and revised the manuscript. JFG developed the initial concept and search strategy for the study, contributed to development of the protocol and article screening and reviewed and revised the manuscript. MEHO contributed to development of the protocol, and reviewed and revised the manuscript. S-LC contributed to development of the protocol, provided expertise regarding the closed reduction of paediatric forearm fractures and reviewed and revised the manuscript. FJS and AFWH contributed to the conception and development of the study protocol, verified study inclusion decisions and quality assessments and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work. AXCG is the guarantor of the manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.