Busted! Management of paediatric upper limb fractures: not all that it's cracked up to be.

OBJECTIVE: The primary objective was to assess use of splinting prior to X-ray in paediatric ED patients with deformed upper limb fractures. Secondary objectives were to evaluate pharmaceutical analgesia use and the impact of demographic, hospital and clinical variables on splint and analgesia provision.

METHODS: A retrospective study of 1407 paediatric ED patients who received upper limb X-rays. The records of those with fractures requiring manipulation were identified, and reviewed for data on demographics, mode of arrival, triage category, site of fracture, clinician seniority, pain scoring, splint application and analgesic use.

RESULTS: Two hundred and twelve patients had fractures requiring manipulation. Of these, 47 (22%) had a splint applied prior to X-ray and 161 (76%) of patients were prescribed analgesia in the first hour after presentation. A triage category 1 or 2 and arrival by ambulance predicted for splint application. Children with higher recorded pain scores were more likely to receive any analgesia in the first hour (91% with a pain score ≥7 compared with 62% with pain score of ≤6, P < 0.001), and more likely to receive strong analgesia (59% vs 13%, P < 0.001). Those triaged to category 1 or 2 were more likely to receive analgesia in the first hour (P < 0.001).

CONCLUSIONS: This study identified significant shortcomings in ED management of children with deformed upper limb fractures. Only a minority were splinted prior to X-ray, and a quarter did not receive any analgesia in the first hour after presentation. Future study should investigate methods to improve ED management of these patients.