Analgesia for Adult Distal Radius Fracture Manipulation in the Emergency Department: Demand Valve Nitrous Oxide Compared with Intravenous Regional Anaesthesia

Introduction This study compared demand-valve nitrous oxide (Entonox) with intravenous regional anaesthesia (IVRA) as analgesia in adults with distal radius fractures requiring manipulation and reduction (M&R) in the Emergency Department. Materials and methods All adults presenting to the Emergency Department of Changi General Hospital, Singapore between August to December 2000 with closed distal radius fractures requiring M&R were enrolled. Five parameters were measured: pain perception using visual analogue scale (VAS), patient acceptance, procedure time, complication rate and failed manipulation. Results Of the 67 patients enrolled, 32 received IVRA and 35 received Entonox. The average VAS was 2.2 cm for the IVRA group and 5.8 cm for the Entonox group (p<0.0001). The average procedure time was 25.6 minutes for the IVRA group and 11.1 minutes for the Entonox group (p<0.0001). Twenty-seven IVRA patients (84.4%) and 24 Entonox patients (68.6%) would agree to the same analgesia given similar circumstances (p=0.159). Four patients who received Entonox (11.4%) experienced minor complications, while no complications were noted in the IVRA group (p=0.115). Two patients who received IVRA (6.3%) and 8 patients who received Entonox (22.9%) required more than a single attempt at M&R (p=0.086). Conclusion The use of Entonox, compared to IVRA, was associated with significantly shorter procedure time but significantly higher pain scores, with no significant difference in terms of patient acceptance, complication rate or failed manipulation rate. Entonox is an effective analgesic alternative to IVRA in adult patients requiring M&R for distal radius fractures in the Emergency Department. Its use is ideal in situations where IVRA is unsuitable or contraindicated.