Axillary Block for Analgesia During Manipulation of Forearm Fractures in the Pediatric Emergency Department. A Prospective Randomized Comparative Trial

Author(s): Kriwanek, KL., Wan, J., Beaty, JH., Pershad, J

Source: J Pediatr Orthop 26:737-740, 2006.


Forearm fractures are common in children accounting for 3-6% of all fractures.  Closed reduction and cast immobilization is a common treatment.  Although, deep sedation is effective in children, this method does have some risk.  Another option is axillary block regional anesthesia, which is more commonly performed in adults than children.  The purpose of this study is to compare deep sedation with axillary block for anesthesia during closed reduction.  This study was a randomized trial in children eight years or older with isolated forearm fractures. A board certified, fellowship trained, pediatric emergency room investigator performed the axillary blocks before transportation to the radiology suite. Standard precautions were taken during the block including intravenous assess and availability of resuscitation equipment.  A trans-arterial technique was utilized with a 25-gauge needle.

Patients were asked to rate their pain on a modified faces pain scale form before treatment and after deep sedation.  During fracture reduction, an experienced pediatric nurse evaluated the patient’s pain and distress using the Children’s Hospital of Eastern Ontario Pain score.  After fracture reduction and cast immobilization, the orthopaedic consultant was asked to rate his or her level of satisfaction with the randomized technique using a Likert-type scale from 1 to 5.  Before discharge, all patients were again asked to rate faces pain scale.  Subsequently, patients and their families were interviewed at their follow-up visit or via telephone.

Over a 6-month period, 43 patients were enrolled in the study.  Two patients were lost to follow-up and one parent could not be contacted in the axillary block group.  Eleven patients in the axillary block group were determined to have incomplete blocks.  Two had failed blocks that required supplemental analgesia.  The results indicate no statistical difference in the Children’s Hospital of Eastern Ontario Pain Scale.  Similarly, there was little difference in the secondary outcome measures.

A variety of anesthetic techniques are available in children during closed reduction.  This study suggests that axillary block is an effective option in children.  The trans-arterial method was successful in the vast majority of patients.  There were some incomplete blocks that did not require additional analgesia.  A small sample size does create the possibility of type II error.  In addition, axillary block in children requires considerable expertise that may not be available in the community.  In fact, many pediatric institutions do not have physicians that are skilled in regional anesthesia within the emergency room setting.  If available, this technique should be considered as an option to provide pain relief during and after closed reduction.


Pediatric, Forearm, Fracture, Anesthesia, Regional, Axillary, Block

Related Links
J Pediatr Orthop