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Comparing the Effectiveness of Modified Forearm and Conventional Minidose Intravenous Regional Anesthesia for Reduction of Distal Forearm Fractures in Children

Werk, Lloyd N. MD, MPH*; Lewis, Marjorie MD; Armatti-Wiltrout, Stacey MA, MS*; Loveless, Eric A. MD

Journal of Pediatric Orthopaedics: June 2008 - Volume 28 - Issue 4 - p 410-416
doi: 10.1097/BPO.0b013e31816d7235
Trauma: Original Article

Background: Minidose intravenous regional anesthesia (IVRA) and modified forearm IVRA have been used for closed reduction of forearm fractures and for hand surgery in children.

Methods: Children (5-17 years old) with forearm fractures presenting to a pediatric emergency department were enrolled in a randomized controlled trial to test if modified forearm and minidose IVRA together would provide improved analgesia with reduced risk of anesthetic toxicity compared with conventional minidose IVRA. Pain was assessed using a visual analog scale (FACES) and an objective pain scale (OPS) score at baseline and at critical times. Spearman rank correlation and repeated-measures analysis of variance were used to compare interobserver pain measures and detect differences between the groups over time.

Results: Among the 62 patients in the study, no significant differences were observed between groups in objective measures of blood pressure, oxygen saturation, and heart rate at baseline, 5 minutes after IVRA, during surgical reduction, and 15 minutes after reduction. Nurses reported patients experienced a reduction in pain of 2.5 (SD, 3.1) on FACES and 2.3 (SD, 3.1) on OPS at 5 minutes after sedation (P < 0.001 for both). From time of reduction to 15 minutes after the procedure, FACES score declined 1.7 (SD, 3.4) (P = 0.001), and OPS declined 2.1 (SD, 3.6) (P = 0.002). No significant differences were found between experimental arms.

Conclusion: The modified forearm minidose IVRA procedure is an acceptable alternative for the relief of pain that usually accompanies the manipulation and reduction of forearm fractures but does not appear to provide additional pain relief compared with conventional minidose IVRA.

Level of Evidence: Level I, therapeutic study.

From the *Nemours Foundation, Clinical Management Program, Orlando, and Departments of †Anesthesiology and ‡Orthopaedics, Nemours Children's Clinic, Jacksonville, FL.

None of the authors received financial suppport for this study.

Reprints: Lloyd N. Werk, MD, MPH, Nemours Foundation, Clinical Management Program, 4901 Vineland Rd, Suite 300, Orlando, FL 32811.

© 2008 Lippincott Williams & Wilkins, Inc.