Overview
Definition:
Fracture reduction involves realigning fractured bone fragments to their anatomical position, essential for optimal healing and function
In pediatrics, this procedure is often coupled with analgesia (pain relief) and sedation (a state of reduced irritability and awareness) to ensure patient comfort, cooperation, and safety, particularly for younger or more anxious children.
Epidemiology:
Fractures are common in children, with an incidence of approximately 1 in 4 children experiencing at least one fracture before the age of 16
The most common sites include the forearm, wrist, clavicle, and tibia
The need for reduction and sedation varies significantly with fracture type, displacement, and child's age and temperament.
Clinical Significance:
Effective pain management and appropriate sedation during fracture reduction are critical for minimizing patient distress, preventing psychological trauma, facilitating successful reduction and immobilization, reducing the risk of complications, and improving overall patient and family satisfaction
Inadequate management can lead to increased pain, anxiety, prolonged hospital stays, and potential long-term behavioral issues.
Age Considerations
Infants And Toddlers:
These age groups often have a limited ability to articulate pain and may exhibit distress through crying, irritability, and behavioral changes
They are also more susceptible to respiratory depression with sedatives
Non-pharmacological methods combined with judicious pharmacological agents are key.
Preschoolers:
Can verbalize pain but may have difficulty localizing it
Fear and anxiety are prominent
Sedation strategies should aim for anxiolysis and cooperation
Parental presence can be beneficial but requires careful management.
School Aged Children:
Better able to communicate pain and cooperate with procedures
Pain assessment is more straightforward
Psychological preparation is crucial.
Adolescents:
Exhibit adult-like pain perception and can have significant anxiety and fear related to the injury and procedure
Their input in the pain management plan is important
Risk of substance abuse should be considered in older adolescents.
Clinical Presentation
Symptoms:
Severe pain at the injury site
Inability to bear weight or move the affected limb
Visible deformity of the limb
Swelling and bruising around the fracture
Tenderness to palpation over the bone
Audible or palpable snap at the time of injury.
Signs:
Deformity (angulation, shortening, rotation)
Crepitus on palpation (though often avoided)
Open wounds or skin tenting over the fracture site
Pallor or cyanosis distal to the fracture (suggesting vascular compromise)
Swelling
Ecchymosis.
Diagnostic Criteria:
Diagnosis is typically based on a history of trauma followed by characteristic clinical signs and confirmed by radiographic evidence of a bone discontinuity
The decision for reduction is based on the degree of displacement, angulation, shortening, or involvement of a joint surface.
Diagnostic Approach
History Taking:
Mechanism of injury is crucial (e.g., fall, direct blow, twisting)
Time of injury
Previous fractures or orthopedic conditions
Allergies
Medications
Last oral intake (important for sedation)
Pain assessment using age-appropriate scales (e.g., FLACC, Numeric Rating Scale).
Physical Examination:
Assess neurovascular status distal to the injury (pulses, sensation, motor function, capillary refill)
Inspect for open wounds, swelling, bruising, and deformity
Palpate gently to localize tenderness
Examine adjacent joints
Assess the entire limb, not just the presumed fracture site.
Imaging:
Standard radiographic views (anteroposterior and lateral) of the affected bone and adjacent joints are essential
For specific fractures, oblique views or specialized imaging like CT may be required
X-rays are used to assess fracture pattern, displacement, angulation, and shortening, guiding the need for reduction.
Differential Diagnosis:
Soft tissue injuries (sprains, strains)
Dislocations
Growth plate injuries (Salter-Harris fractures)
Pathological fractures (e.g., due to tumors or metabolic bone disease)
Abuse-related fractures.
Management
Analgesia Options:
Non-pharmacological: distraction, ice, splinting, parental presence
Pharmacological: Acetaminophen (paracetamol) 10-15 mg/kg/dose PO/PR q4-6h
Ibuprofen 5-10 mg/kg/dose PO q6-8h (if >6 months)
Opioids: Morphine 0.1 mg/kg/dose IV/IO q2-4h (max 5mg)
Fentanyl 0.5-1 mcg/kg/dose IV/IO q5-15min (max 25mcg).
Sedation Options:
Mild Sedation/Anxiolysis: Oral midazolam 0.25-0.5 mg/kg (max 10mg) 20-30 mins prior
Moderate Sedation: Ketamine 1-2 mg/kg IV/IO + Midazolam 0.05-0.1 mg/kg IV/IO
Propofol 1-3 mg/kg IV/IO (bolus followed by infusion), typically requires deeper monitoring
Nitrous oxide (inhalation) 30-50% with oxygen.
Sedation Planning:
Assess patient's risk factors (age, comorbidities, airway status, last oral intake)
Choose agent(s) based on procedure complexity, patient age, and desired level of sedation
Have resuscitation equipment and trained personnel readily available
Continuous monitoring of vital signs (heart rate, respiratory rate, oxygen saturation, blood pressure) and level of consciousness is mandatory.
Reduction Techniques:
Closed reduction: Manual manipulation of the bone fragments
Open reduction: Surgical exposure and manipulation of fragments, typically when closed reduction fails or is contraindicated
External fixation or casting is usually applied after successful reduction.
Post Reduction Care:
Immobilization with cast or splint
Strict neurovascular checks
Pain management as needed
Radiographic confirmation of reduction adequacy
Education for parents/caregivers regarding cast care and signs of complications.
Complications
Early Complications:
Neurovascular injury (nerve damage, vascular compromise)
Compartment syndrome
Open fracture contamination and infection
Soft tissue injury from manipulation
Over-sedation or adverse reaction to anesthetic agents.
Late Complications:
Malunion or non-union of the fracture
Growth plate injury leading to limb length discrepancy or angular deformity
Joint stiffness and contractures
Post-traumatic arthritis
Reflex sympathetic dystrophy (complex regional pain syndrome).
Prevention Strategies:
Thorough pre-procedure assessment of neurovascular status
Judicious use of sedatives and analgesics with continuous monitoring
Gentle handling of tissues during reduction
Appropriate immobilization techniques
Prompt recognition and management of compartment syndrome
Prophylactic antibiotics for open fractures.
Key Points
Exam Focus:
Prioritize patient safety during sedation
Recognize signs of compartment syndrome
Understand age-specific pain assessment tools
Know the standard dosages for common pediatric analgesics and sedatives.
Clinical Pearls:
Always perform and document a thorough neurovascular assessment before and after reduction
The "can't miss" diagnosis is compartment syndrome
Parental presence can be comforting but ensure they understand their role and risks
Adequate analgesia is paramount even before sedation.
Common Mistakes:
Underestimating pain in infants
Inadequate monitoring during sedation
Delayed recognition of neurovascular compromise or compartment syndrome
Over-reliance on one agent for both analgesia and sedation
Not considering growth plate involvement in pediatric fractures.