Effect of virtual reality on pain and stress in children during Kirschner-wire removal after fracture treatment: a randomized clinical trial

Abstract Background Removal of Kirschner wires (K-wires) after fracture treatment in the upper limb is unpleasant for children. The aim of this study was to evaluate whether virtual reality (VR) distraction could improve pain and the overall experience for children. Methods An RCT was performed in a single outpatient fracture clinic, where children (aged 6–15 years) were randomized 1 : 1, in three age strata, to additional VR or standard of care. Pain perception was assessed using the Wong–Baker Faces Pain Rating Scale by neutral observers and later by the patients and their guardians. Further measures included the Face/Legs/Activity/Cry/Consolability (FLACC) Pain Scale, the modified Yale Pain Anxiety Scale (mYPAS), and questionnaires, as well as objective data, such as heart rate variability and blood pressure. Results A total of 146 patients were recruited into the trial. The VR group showed significantly less pain on the Wong–Baker Faces Pain Rating Scale (OR 0.23 (95% c.i. 0.12 to 0.43)) compared with the control group. Observers rated the pain >2 for 43% of patients in the VR group and 74% of patients in the control group. Observer scales (the FLACC Pain Scale and the mYPAS) during K-wire removal also indicated less pain (OR 0.36 (95% c.i. 0.19 to 0.24) and 0.29 (95% c.i. 0.16 to 0.52) respectively). The difference in pain rated >2 between the VR and control group was smaller directly after (59% versus 69% respectively) and 2 weeks after (58% versus 70% respectively) K-wire removal. Children in the VR group were less aware of the painful stimulus directly after and 2 weeks after wire extraction. Conclusion VR distraction effectively reduces pain during K-wire removal in children. VR positively impacts the procedural memory of children. Registration number DRKS00020229 (Deutsches Register Klinischer Studien (DRKS; that is the German Clinical Trials Register); date of registration 10 December 2019).