Corticosteroid Injections for Nerve Pain After Fracture
Corticosteroid injections are NOT routinely recommended for nerve pain after fractures, as the evidence is limited and conflicting, with potential risks outweighing uncertain benefits in most post-fracture scenarios.
Evidence-Based Rationale
Limited Support for Post-Fracture Nerve Pain
The available evidence does not strongly support corticosteroid injections specifically for nerve pain following fractures:
Radicular pain guidelines recommend epidural steroid injections for radiculopathy and radicular pain, but these are primarily for chronic spinal nerve compression, not acute post-fracture nerve injury 1.
One case series reported successful use of thoracic epidural steroid injections for rib fracture pain, but this represents the first and only published series of this approach, indicating it is not standard practice 2.
Animal studies suggest corticosteroids may reduce substance P expression and inflammatory markers after nerve root compression and decompression, but this is experimental evidence that has not translated to established clinical practice for post-fracture nerve pain 3.
Specific Context: Complex Regional Pain Syndrome (CRPS)
The one exception where corticosteroids show promise is for CRPS developing after fracture:
Oral prednisone (not injections) has growing evidence and support from international guidelines for treating acute CRPS after fracture, with case series showing resolution of pain, swelling, and disability 4.
This represents a disease-modifying treatment for CRPS specifically, not general post-fracture nerve pain 4.
Preferred Alternatives for Post-Fracture Pain Management
Multimodal analgesia without corticosteroid injections is the evidence-based approach:
Peripheral nerve blocks with local anesthetics (not steroids) are strongly recommended for fracture-related pain, particularly in elderly patients with hip and long-bone fractures, reducing opioid use, pain scores, and hospital length of stay 1.
Scheduled non-opioid analgesics including acetaminophen, NSAIDs, and gabapentinoids form the foundation of post-fracture pain management 1.
Regional anesthesia techniques (fascia iliaca blocks, peripheral nerve blocks) provide superior pain control compared to systemic medications alone for fracture pain 1.
Significant Safety Concerns
Corticosteroid injections carry documented risks that are particularly concerning in fracture patients:
Tendon and fascial ruptures are the predominant complications reported with corticosteroid injections in musculoskeletal injuries 5.
Systemic effects include hyperglycemia, adrenal suppression, decreased bone mineral density with increased fracture risk, and immunosuppression with infection risk 1, 6.
Cartilage damage and postoperative joint infection are additional concerns with intra-articular corticosteroid injections 6.
These risks are particularly problematic in patients already dealing with bone healing after fracture 5, 6.
Clinical Decision Algorithm
For nerve pain after fracture, follow this approach:
First-line: Implement multimodal analgesia with scheduled acetaminophen, NSAIDs, and gabapentinoids 1.
Second-line: Consider peripheral nerve blocks with local anesthetics (single-shot or continuous) for regional pain control 1.
If CRPS develops: Consider oral prednisone (not injections) following Budapest criteria diagnosis 4.
Avoid: Routine corticosteroid injections for general post-fracture nerve pain given lack of evidence and documented risks 2, 5.
Critical Pitfalls to Avoid
Do not confuse chronic radiculopathy guidelines (which support epidural steroids) with acute post-fracture nerve pain—these are different clinical entities 1.
Do not delay early fracture stabilization (within 24 hours for long bones) while pursuing pain management, as surgical timing affects outcomes more than analgesic choice 1.
Do not use corticosteroid injections near tendons or in areas requiring healing, given rupture risk 5.
Recognize CRPS early (within weeks of fracture) if considering corticosteroids, as this is the only post-fracture scenario with supporting evidence, and oral administration is preferred over injection 4.