Clinical Practice Guidelines

Local Anaesthetic Manipulation and Plaster LAMP

  • Doctors must discuss previous experience and training in this procedure with the Director of the Emergency Department before proceeding, and should be fully familiar with the equipment used.


    Children over 5 yrs with forearm fractures requiring manipulation - some younger children if very cooperative. Distressed or non-compliant children may be better treated Under GA.


    Prior to X-Ray

    • Give adequate pain relief
      • Painstop 1.0mL/kg
      • or Pethidine 1.0-1.5mg/kg IM
      • or Morphine 0.1-0.2 mg/kg IM
    • Keep child nil orally.
    • Put EMLA/amethocaine on both hands.

    Once decision is made to proceed to LAMP

    • All LAMP procedures are to be ED admissions. A yellow form should be taken to the ward clerks to be processed. Informed consent must be obtained from parents.
    • Procedure must be performed in Proceedure Room with full resuscitation equipment. Check all Equipment.
    • Notify radiology to ensure availability of staff prior to commencing.


    • Two doctors must be present.
    • Apply a tourniquet to the affected arm.
    • Insert an i.v. cannula (not a butterfly) into a distal vein of both arms
    • Elevate the arm above the level of the child's heart for 1 minute with compression of the brachial artery.
    • Inflate the tourniquet cuff to 200 mmHg. This reading is maintained throughout the procedure and remains the responsibility of the second attending doctor.
    • Infuse Lignocaine 0.5% 0.6mls/kg (3 mg/kg); max dose 40ml.
    • Commence manipulation only after full anaesthesia has been obtained (usually.takes 5-10 minutes).
      Note: Nitrous oxide or intravenous opiate may be useful as an adjunct in some children.
    • Apply plaster to the forearm (below elbow).
    • Arrange portable post-reduction film in ED. If possible wait until the X-ray is available to assess the position post-manipulation before releasing the tourniquet.
    • Release the tourniquet cuff.
      Note:Not to be released before 20 minutes after lignocaine infusion. 
      Complete the plaster cast (above elbow).

    After the Procedure

    • The child may be discharged from the ED after the cuff is released.
    • Arrange plaster check LMO on the following day.
    • Organise Fracture Clinic and X-ray appointment at 5-7 days.
    • Complete yellow Discharge Summary and operative notes on Surgical Short Stay form.