Clinical Practice Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Mar 18, 2018; 9(3): 50-57
Published online Mar 18, 2018. doi: 10.5312/wjo.v9.i3.50
Use of ketamine sedation for the management of displaced paediatric forearm fractures
Anatole Vilhelm Wiik, Poonam Patel, Joanna Bovis, Adele Cowper, Philip Socrates Pastides, Alison Hulme, Stuart Evans, Charles Stewart
Anatole Vilhelm Wiik, Department of Surgery and Cancer, Charing Cross Hospital, London W6 8RF, United Kingdom
Poonam Patel, Adele Cowper, Charles Stewart, Department of Paediatric Emergency, Chelsea and Westminster Hospital, London SW10 9NH, United Kingdo
Joanna Bovis, Philip Socrates Pastides, Alison Hulme, Stuart Evans, Department of Trauma and Orthopaedics, Chelsea Westminster Hospital, London SW10 9NH, United Kingdom
Author contributions: Wiik AV and Stewart C designed the study; Wiik AV and Stewart C collected the data; Wiik AV, Patel P, Bovis J and Cowper A analysed the results; Wiik AV, Patel P, Bovis J, Cowper A, Pastides PS, Hulme A, Evans S and Stewart C interpreted and wrote the report.
Institutional review board statement: This was a registered service improvement project at Chelsea Westminster hospital audit department (QIP LA-353). Ethical approval was not sought nor required as it was part of a service evaluation project for the paediatric emergency department at Chelsea Westminster hospital.
Informed consent statement: Informed consent was obtained prior to any treatment from the parent or guardian.
Conflict-of-interest statement: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Data sharing statement: Dataset available from the corresponding author.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Anatole Vilhelm Wiik, BSc, MBBS, MD, Doctor, Lecturer, Department of Surgery and Cancer, Charing Cross Hospital, Fulham Place Road, London W6 8RF, United Kingdom. a.wiik@imperial.ac.uk
Telephone: +44-20-33130970 Fax: +44-20-33115218
Received: November 3, 2017
Peer-review started: November 4, 2017
First decision: December 27, 2017
Revised: January 4, 2018
Accepted: February 4, 2018
Article in press: February 5, 2018
Published online: March 18, 2018
Processing time: 132 Days and 12.4 Hours
Abstract
AIM

To determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department.

METHODS

Following an agreed interdepartmental protocol, fractures of the radius and ulna (moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and post manipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken.

RESULTS

During the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate (3), fractures of both radius and ulna (6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of £1470, the overall study saving being £14700.

CONCLUSION

Ketamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.

Keywords: Paediatrics; Forearm fractures; Displaced fractures; Ketamine; Salter Harris; Procedural sedation

Core tip: Displaced paediatric forearm fractures can be safely and effectively treated in the emergency department with ketamine procedural sedation.