Emergency Department Procedural Sedation Versus Operating-Theater General Anesthesia for Closed Reduction of Pediatric Forearm Fractures: A Systematic Review.

Displaced pediatric forearm fractures requiring closed reduction are traditionally managed in the operating theater under general anesthesia (GA). However, emergency department (ED)-based procedural sedation may reduce treatment delays, admissions, and resource utilization. This systematic review evaluated clinical outcomes, safety, repeat intervention, and resource implications of ED procedural sedation compared with theater-based GA and identified factors associated with unsuccessful ED management. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. MEDLINE, the Cochrane Library, Web of Science, and Scopus were searched from 2000 to June 2026. Studies evaluating children with displaced or angulated forearm fractures undergoing closed reduction with ED sedation or theater-based GA were eligible. Risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) and Quality in Prognosis Studies (QUIPS) tools. Due to substantial clinical and methodological heterogeneity, findings were synthesized narratively. Six observational studies met the inclusion criteria, including four direct comparative studies and two analytical observational studies. No randomized controlled trials were identified. The four comparative studies included a total of 958 children and evaluated various ED sedation approaches, including ketamine, nitrous oxide-based regimens, and opioid combinations. Most studies were at high risk of bias, primarily due to confounding by fracture severity, treatment selection, and differences in resources between ED and theater settings. ED and theater management demonstrated similar initial reductions in quality and cast-quality outcomes across the available studies. Evidence regarding redisplacement and repeat interventions was inconsistent: one study reported higher remanipulation rates after ED reduction, whereas others found no significant differences. ED management was consistently associated with shorter treatment times, reduced admission, shorter length of stay, and lower resource utilization. Factors associated with unsuccessful ED reduction included delayed presentation, non-distal fracture location, and increasing age. Implementation of a structured ED pathway was associated with higher ED treatment rates and fewer failed reductions, although causal inference was limited by the study design. ED procedural sedation appears to be a feasible option for selected pediatric forearm fractures requiring closed reduction, with potential benefits in efficiency and resource use. However, current evidence remains limited by observational study designs, selection bias, and heterogeneous treatment protocols. Further prospective studies are required to establish optimal patient selection criteria, safety, and the comparative effectiveness of ED- and theater-based management.