What are the options for pain management in a 15-year-old patient with an ankle fracture?

From the Guidelines

For a 15-year-old with an ankle fracture, pain management should prioritize a multimodal approach, starting with regular administration of intravenous acetaminophen every 6 hours as the first line of treatment, as recommended by the most recent guidelines 1. This approach is based on high-quality evidence and is aimed at managing acute trauma pain effectively. The following steps can be taken for pain management:

• Administer acetaminophen (Tylenol) at 650-1000 mg every 6 hours (not exceeding 4000 mg daily)
• Consider adding NSAIDs like ibuprofen (Motrin, Advil) at 400-600 mg every 6 hours with food (maximum 2400 mg daily) for severe pain, taking into account potential adverse events and pharmacological interactions, as suggested by 1.
• Ice the ankle for 15-20 minutes every 2-3 hours during the first 48-72 hours, keeping a thin cloth between the ice and skin, based on the principles outlined in 1.
• Elevate the ankle above heart level when possible to reduce swelling and pain.
• Rest is crucial, and the teen should follow weight-bearing restrictions from their doctor.
• A properly fitted cast or boot is essential for immobilization and pain reduction.
• For severe pain, the doctor might prescribe a short course of low-dose opioids like hydrocodone/acetaminophen, but these should be used minimally due to risks of dependence and side effects in adolescents.
• Non-medication approaches like distraction techniques, guided imagery, or relaxation exercises can also help manage pain, as part of a multimodal analgesic approach 1. If pain worsens suddenly, is uncontrolled with prescribed medications, or is accompanied by numbness, tingling, or color changes, seek immediate medical attention as these could indicate complications requiring urgent care.

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)] . Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases with oxycodone hydrochloride tablets and adjust the dosage accordingly [see Warnings and Precautions (5.3)] . 2. 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 a 15-year-old patient with ankle fracture pain, the dosage of oxycodone hydrochloride tablets should be initiated at 5 to 15 mg every 4 to 6 hours as needed for pain. It is essential to monitor patients closely for respiratory depression and adjust the dosage accordingly. The dosage should be titrated based on the individual patient's response to their initial dose of oxycodone hydrochloride tablets. 2

From the Research

Ankle Fracture Pain Management for 15-Year-Old

Overview of Treatment Options

• Ankle fractures in children can be treated with various methods, including splints, casts, and surgical fixation 3.
• The choice of treatment depends on the severity and complexity of the fracture.

Non-Surgical Management Options

• Studies have compared non-surgical management options, such as the Aircast Air-Stirrup ankle brace versus a rigid cast 3.
• The results showed low-quality evidence of clinically important differences in function scores at four weeks in favor of the brace groups.
• The use of an ankle brace was associated with an earlier return to pre-injury activity and less pain at four weeks.

Regional Anesthesia for Ankle Fracture Reduction

• The ankle block, a form of regional anesthesia, is increasingly used for ankle fracture reduction due to its ability to provide localized pain relief while minimizing systemic side effects 4.
• Ultrasound guidance has enhanced the precision and success of the procedure, leading to improved outcomes.
• However, patients may experience rebound pain after the block wears off, and thorough information and education are crucial to prevent undesirable responses 5.

Patient Experiences and Expectations

• Patients' expectations and experiences with peripheral nerve blocks in ankle fracture surgery have been explored through semi-structured interviews 5.
• The results showed that patients valued the mental alertness, ability to ambulate, and efficient pain relief provided by the blocks, but had difficulties understanding the effect and course of the nerve blocks.