Fracture manipulation management for RHC ED

GGC Paediatric Guidelines
NHS GGC
Prior to any manipulation of fractures in RHC ED then please liaise with the ED coordinator to ensure there is clinical capacity.
Patients not in RHC ED - prior to transfer to RHC ED for fracture manipulation in the ED please liaise with the ED coordinator to ensure there is clinical capacity.

In times of peak clinical activity it may be appropriate to stabilize the fracture site in a back-slab and arrange return to RHC ED at a more appropriate time for manipulation in the ED.

For dislocations or fractures where there is neurovascular compromise or concerns regarding skin integrity - Please liaise directly with the Consultant in Charge for RHC ED to coordinate appropriate and timely management of these clinical priority patients.

Fracture management algorithm

Box A – Fractures appropriate for manipulation in ED must meet both inclusion criteria and have no exclusion criteria.

Inclusion

  • Simple fracture which is angulated or partly displaced. (any degree of angulation can be considered)
  • The fracture is easily reducible with a simple reduction manoeuvre, preferably at the first attempt

Exclusion

  • Off-ended distal radius fractures (in the absence of NV compromise)
  • Complex reduction manoeuvres are likely required

Box B

The decision to use IV ketamine sedation is that of the emergency department consultant and nurse in charge and the following factors should be taken into consideration:

Time of day, Safe staffing levels, Staff skill mix, Age of patient, Contraindications

Consider portable “hot” XR in resus whilst patient still under sedation to check position post manipulation.

Ketamine for PPS SOP

Editorial Information

Last reviewed: 02/02/2026

Next review date: 28/02/2029

Author(s): Dr Gillian Campbell - Consultant in Paediatric Emergency Medicine, RHCG on behalf of RHCG ED. Correspondence author: Dr Steve Foster..

Version: 4

Approved By: RHCG ED & Paediatric Orthopaedic services RHCG