From the Guidelines
The recommended medical management for fracture pain in the elderly begins with intravenous acetaminophen every 6 hours as first-line treatment in a multimodal analgesic approach. This approach is based on the strongest and most recent evidence from the 2023 WSES guidelines on the management of trauma in elderly and frail patients 1.
Key Considerations
- For moderate to severe pain, considering the addition of NSAIDs may be necessary, taking into account potential adverse events and pharmacological interactions, as suggested by the guidelines 1.
- The implementation of a Multi-Modal-Analgesia (MMA) approach, including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and opioids only for breakthrough pain, is recommended for elderly injured patients 1.
- Peripheral nerve blocks placement in elderly patients with acute hip fractures at the time of presentation can reduce preoperative and postoperative opioid use for analgesia, as supported by strong evidence 1.
- Epidural analgesia and regional anesthesia can be considered for controlling severe pain in acute hip fractures in selected elderly patients, although the recommendation is weaker due to moderate quality evidence 1.
Multimodal Approach
A multimodal approach to pain management is crucial, incorporating non-pharmacological methods such as:
- Proper positioning
- Ice for the first 48-72 hours followed by heat therapy
- Physical therapy when appropriate
- Assistive devices to reduce weight-bearing on affected limbs Regular reassessment of pain control and medication side effects is essential, with dose adjustments based on renal function, which often declines with age 1.
Evidence Base
The evidence from recent studies, including those published in 2024, emphasizes the importance of effective pain management in elderly patients with fractures, highlighting the need for a balanced approach that minimizes adverse effects while providing adequate pain relief 1.
Conclusion is not allowed, so the answer ends here.
From the FDA Drug Label
Elderly patients (aged 65 years or older) may have increased sensitivity to oxycodone. In general, use caution when selecting a dosage for an elderly patient, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy Respiratory depression is the chief risk for elderly patients treated with opioids, and has occurred after large initial doses were administered to patients who were not opioid-tolerant or when opioids were co-administered with other agents that depress respiration Titrate the dosage of oxycodone hydrochloride tablets slowly in geriatric patients and monitor closely for signs of central nervous system and respiratory depression
The recommended medical management for fracture pain in the elderly involves:
- Caution when selecting a dosage for an elderly patient
- Starting at the low end of the dosing range
- Titration of the dosage slowly in geriatric patients
- Close monitoring for signs of central nervous system and respiratory depression 2
From the Research
Medical Management of Fracture Pain in the Elderly
The medical management of fracture pain in the elderly involves a multifaceted approach to ensure effective pain relief while minimizing adverse effects.
- The use of multimodal pain control is recommended for early mobility and decreased narcotic requirement in hip fractures 3.
- Regional analgesia is supported by strong evidence to improve preoperative pain control in hip fractures 4.
- Multimodal pain management after hip fracture surgery is also recommended 4.
- The effect of NSAIDs on bone healing has not been conclusively demonstrated, and the literature is still inconclusive regarding the superiority of either spinal or general anesthesia during operative treatment 3.
- Oxycodone/acetaminophen resulted in slightly greater pain relief than acetaminophen in patients with acute musculoskeletal pain refractory to oral ibuprofen, but this was associated with more medication-related adverse events 5.
Pain Management Strategies
Pain management strategies for fractures in the elderly include:
- Hematoma block for distal radius fracture pain during reduction 3
- Soft dressing and use of a compression glove for postoperative pain control and edema in distal radius fractures 3
- Hematoma block or procedural sedation for ankle fractures 3
- Multimodal pain control for long bone fracture pain management 3
Post-Operative Rehabilitation
Post-operative rehabilitation is crucial in the management of lower extremity fractures in the elderly, with a focus on early post-operative weight bearing to minimize immobility and associated risks 6.