What is the best pain medication for acute fracture pain?

Best Pain Medication for Acute Fracture Pain

Intravenous acetaminophen administered every 6 hours is recommended as first-line treatment for acute fracture pain as part of a multimodal analgesic approach. 1

First-Line Treatment Options

Acetaminophen (Paracetamol)

• Recommended as baseline treatment for all pain intensities in fractures 1
• Administration:
  • Intravenous: Every 6 hours (strong recommendation based on high-quality evidence)
  • Oral: 500-1000mg every 4-6 hours (maximum 4-6g daily) 1
• Benefits: Effective pain control with minimal side effects
• Caution: Monitor for hepatotoxicity, especially at higher doses

NSAIDs

• Consider adding NSAIDs for patients with severe fracture pain 1
• Options:
  • Ibuprofen: 400-600mg every 6-8 hours (oral)
  • Diclofenac: 50mg every 8 hours (oral)
  • Naproxen: 250-500mg every 12 hours (oral)
• Caution: Consider potential adverse events including gastrointestinal and renal toxicity, especially in elderly patients

Multimodal Analgesia Approach

For optimal pain control, implement a multimodal approach including:

1. Acetaminophen as baseline
2. NSAIDs (if not contraindicated)
3. Regional anesthesia techniques when appropriate
4. Opioids only for breakthrough pain at lowest effective dose for shortest duration 1

Regional Anesthesia Options

For Hip Fractures

• Peripheral nerve blocks are strongly recommended at presentation to reduce opioid use 1
• Options:
  • Femoral nerve block
  • Posterior lumbar plexus block (more effective but higher risk of complications)

For Rib Fractures

• Thoracic epidural and paravertebral blocks strongly recommended in combination with systemic analgesics 1
• Benefits: Improved respiratory function, reduced opioid consumption, fewer infections and delirium

Opioid Options (For Breakthrough Pain Only)

When opioids are necessary for breakthrough pain:

• Use lowest effective dose for shortest duration 1
• Options:
  • Morphine: Starting dose 5-10mg IV or 20-40mg oral 1
  • Oxycodone: Starting dose 5mg oral (comparable efficacy to hydrocodone but with fewer side effects like constipation) 2

Special Considerations

Elderly Patients

• Higher risk of adverse effects from all medications
• Acetaminophen remains first choice
• Use caution with NSAIDs due to increased risk of GI bleeding and renal impairment
• Consider regional anesthesia techniques when possible 1

Pediatric Patients

• Ibuprofen may provide better pain control than acetaminophen with codeine for arm fractures 3
• Better tolerated with fewer side effects

Non-Pharmacological Measures

• Immobilization of fractured limbs
• Application of ice packs
• Proper positioning
• These should be used in conjunction with pharmacological approaches 1

Common Pitfalls to Avoid

1. Overreliance on opioids as first-line treatment
2. Failure to implement multimodal analgesia
3. Inadequate assessment of pain control
4. Not considering regional anesthesia options when appropriate
5. Not adjusting medication based on patient risk factors (age, comorbidities)

For post-operative pain after fracture fixation, evidence suggests that acetaminophen alone may be non-inferior to acetaminophen plus tramadol for patient satisfaction with pain control 4, supporting the approach of using simpler analgesic regimens when possible.