What are the best methods of pain control in a 5-year-old female (YOF) with a displaced finger fracture during reduction?

Optimal Pain Control for Displaced Finger Fracture Reduction in a 5-Year-Old Female

Regional nerve block with a long-acting local anesthetic (bupivacaine, levobupivacaine, or ropivacaine) combined with nonpharmacologic techniques is the most effective method for pain control during finger fracture reduction in a 5-year-old female.

Assessment and Preparation

• Assess the fracture pattern and displacement using appropriate radiographic views before attempting reduction
• Evaluate neurovascular status of the affected finger
• Consider the child's anxiety level and previous experiences with medical procedures

Pain Management Algorithm

First-line Approach (Recommended)

1. Regional Nerve Block

   • Digital nerve block using long-acting local anesthetic:
     • Bupivacaine 0.25% (maximum 1 ml/kg = 2.5 mg/kg) 1
     • Levobupivacaine 0.25% (maximum 1 ml/kg = 2.5 mg/kg) 1
     • Ropivacaine 0.2% (maximum 1.5 ml/kg = 3 mg/kg) 1
   • Use ultrasound guidance when available for increased precision and safety

2. Concurrent Nonpharmacologic Techniques

   • Facilitated tucking (positioning)
   • Distraction techniques appropriate for a 5-year-old (toys, videos, storytelling)
   • Parental presence for comfort and reassurance 1
   • Consider offering breastfeeding or expressed human milk if applicable 1

Alternative Approaches (If Regional Block Contraindicated)

1. Topical Anesthesia

   • Apply topical anesthetics (EMLA or tetracaine gel) 30-60 minutes before procedure 1
   • Consider lidocaine-containing preparations 2

2. Oral/Systemic Medications

   • Oral sucrose solution for mild to moderate pain relief 1
   • Consider oral analgesics before the procedure:
     • Paracetamol (acetaminophen): 15 mg/kg
     • NSAID (if no contraindications): appropriate weight-based dosing

3. Procedural Sedation (For severely displaced fractures or extremely anxious child)

   • Should be performed with appropriate monitoring and by trained personnel
   • Options include:
     • Intranasal or IV midazolam
     • Low-dose ketamine
     • Nitrous oxide (if available)

Post-Reduction Management

• Apply appropriate immobilization (buddy taping is recommended over splinting for increased comfort) 3
• Ensure early finger mobilization to minimize stiffness 4
• Schedule follow-up within 1 week to assess healing and alignment

Special Considerations and Pitfalls

• Avoid excessive sedation: Children may have difficulty articulating symptoms like pain and paresthesia, which are important warning signs for potential complications 1
• Monitor for compartment syndrome: Although rare in finger fractures, children may present with anxiety, agitation, and increased analgesic requirements as signs 1
• Pain assessment: Use age-appropriate validated pain scales to evaluate pain before, during, and after the procedure 1
• Dosing precision: Calculate medication doses based on accurate weight to prevent under or overdosing
• Parental education: Provide clear instructions on post-procedure pain management and signs of complications

Evidence Quality and Considerations

The European Society for Paediatric Anaesthesiology (ESPA) provides strong recommendations for regional anesthesia techniques with specific dosing guidelines for local anesthetics in children 1. The American Academy of Pediatrics emphasizes the importance of both pharmacologic and nonpharmacologic pain prevention strategies 1. Recent research demonstrates that buddy taping after reduction provides superior comfort compared to splinting with equivalent outcomes for fracture healing 3.

Regional nerve blocks offer superior pain control with minimal systemic effects, making them ideal for procedural pain management in children. When performed correctly, they provide complete anesthesia to the affected digit while allowing the child to remain alert and cooperative during and after the procedure.