What are the options for pain management in patients with a fracture?

From the Guidelines

Pain management for fractures should prioritize a multimodal approach, incorporating acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) as first-line treatments, alongside non-pharmacological strategies such as immobilization, elevation, and ice application, with the consideration of peripheral nerve blocks for acute hip fractures, as recommended by the most recent and highest quality study 1.

When managing acute fracture pain, it is essential to consider the patient's overall health status, including age, kidney function, and bleeding risk. For elderly patients, the 2023 WSES guidelines recommend a regular administration of intravenous acetaminophen every 6 hours as the first-line treatment in a multimodal analgesic approach 1. Additionally, considering the use of NSAIDs in elderly patients presenting with severe pain is suggested, taking into account potential adverse events and pharmacological interactions 1.

For moderate to severe pain, short-term opioids may be necessary, but their use should be carefully monitored and tapered off as pain improves. Non-pharmacological approaches, such as immobilization with splints or casts, elevation of the injured limb above heart level to reduce swelling, and ice application, can help decrease movement-related pain and swelling.

The use of peripheral nerve blocks, such as thoracic epidural and paravertebral blocks, can be beneficial in controlling severe pain in acute hip fractures and rib fractures, especially in elderly patients 1. However, the decision to use these blocks should be made on a case-by-case basis, considering the patient's overall health status and potential risks.

In terms of specific medications, acetaminophen (650-1000mg every 6 hours, maximum 4000mg daily) and NSAIDs (such as ibuprofen 400-600mg every 6 hours with food) can be used as first-line treatments for acute fracture pain. For moderate to severe pain, short-term opioids such as oxycodone (5-10mg every 4-6 hours) or hydrocodone/acetaminophen (5/325mg every 4-6 hours) may be necessary, but their use should be carefully monitored and tapered off as pain improves.

Key considerations in pain management for fractures include:

• Using a multimodal approach that incorporates medications and non-pharmacological strategies
• Considering the patient's overall health status, including age, kidney function, and bleeding risk
• Using acetaminophen and NSAIDs as first-line treatments for acute fracture pain
• Considering the use of peripheral nerve blocks for acute hip fractures and rib fractures
• Carefully monitoring and tapering off opioid use as pain improves
• Using non-pharmacological approaches, such as immobilization, elevation, and ice application, to decrease movement-related pain and swelling.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

Dosage and Administation: 2. 1 Important Dosage and Administration Instructions Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals [see Warnings and Precautions (5)] Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse [see Warnings and Precautions (5. 1)] .

1. 2 Initial Dosage Use of Oxycodone Hydrochloride Tablets as the First Opioid Analgesic Initiate treatment with oxycodone hydrochloride tablets in a dosing range of 5 to 15 mg every 4 to 6 hours as needed for pain.

For pain management in patients with a fracture, the recommended initial dosage of oxycodone is 5 to 15 mg every 4 to 6 hours as needed for pain 2.

• The dosage should be individualized based on the patient's severity of pain, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse.
• It is essential to use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals.
• Patients should be closely monitored for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases.

From the Research

Pain Management Strategies for Fractures

• The management of pain associated with fractures involves various strategies, including multimodal pain control, regional anesthesia, and non-pharmacological interventions 3.
• For hip fractures, multimodal pain control can help with early mobility and decrease narcotic requirement 3.
• Distal radius fracture pain can be managed with hematoma block during reduction, and a soft dressing or compression glove can be used postoperatively to improve pain control and reduce edema 3.
• Ankle fractures can be reduced with hematoma block, and procedural sedation may reduce the number of reduction attempts for fracture dislocations 3.

Pediatric Fracture Pain Management

• Children have unique needs in pain management, and there is a scarcity of literature on acute fracture pain in pediatric populations 4.
• A thorough review of existing literature is essential to provide guidance on safely and effectively reducing pain associated with children's fractures 4.
• Pain assessment methods, non-pharmacological treatments, and pharmacological treatments are crucial areas to consider in pediatric fracture pain management 4.
• Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for moderate pain, while opioid medications are suggested for severe pain, with detailed information on usage and contraindications for different age groups 4.

Non-Surgical and Non-Pharmacological Management of Osteoporotic Vertebral Fractures

• Exercise and rigid bracing interventions may have a small benefit for pain reduction in patients with osteoporotic vertebral fractures without increasing the risk of harm 5.
• Meta-analyses provided low certainty evidence that exercise interventions and rigid bracing were effective in reducing pain in patients with osteoporotic vertebral fractures 5.
• No differences in harms were found between exercise and no exercise groups, and no health-related quality of life or activity improvements were demonstrated for exercise interventions, bracing, electrotherapy, or multimodal interventions 5.

Management of Musculoskeletal Pain

• Musculoskeletal pain is a challenging condition that affects approximately 47% of the general population, with about 39-45% having long-lasting problems that require medical consultation 6.
• Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of musculoskeletal pain 6.
• Both pharmacological and non-pharmacological treatments, as well as interventional pain therapy, are important to enhance patient recovery, well-being, and improve quality of life 6.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

• Comprehensive guidelines and recommendations are essential to improve the management of acute pain following musculoskeletal injury 7.
• The use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia are recommended 7.
• Connecting patients to psychosocial interventions, considering anxiety reduction strategies, and using physical strategies such as ice, elevation, and transcutaneous electrical stimulation are also recommended 7.