What is the recommended approach to pain management for pediatric shoulder fractures, including the use of nerve blocks?

Nerve Blocks for Pediatric Shoulder Fractures

Peripheral nerve blocks are medically necessary and should be strongly considered for pediatric shoulder fractures, as they provide superior pain control with fewer adverse effects compared to systemic opioids alone, while forming part of a multimodal analgesic approach. 1

Recommended Multimodal Approach

The optimal pain management strategy for pediatric shoulder fractures involves combining regional anesthesia with non-opioid analgesics rather than relying solely on systemic medications 2:

Core Components (All Levels of Care)

• Non-opioid baseline therapy: Administer NSAIDs and/or paracetamol (acetaminophen) started pre-operatively or intra-operatively and continued postoperatively 3, 4
• Regional anesthesia: Upper extremity nerve blocks should be performed when available, as they are safe and effective in experienced hands 2
• Adjunctive medications: Consider IV dexamethasone to prolong block duration and reduce supplemental analgesic requirements 3

Specific Nerve Block Options for Shoulder

Interscalene block is the primary regional technique for shoulder injuries and provides complete pain control and muscle relaxation 5. For shoulder procedures:

• Continuous interscalene block is preferred over single-shot for extended pain relief in surgical cases 3
• Ultrasound guidance should be used whenever available for safety and efficacy 2
• In settings with limited ultrasound availability, nerve stimulator guidance can be used by experienced pediatric anesthesiologists 2

Suprascapular nerve block is an alternative simple and safe technique for shoulder pain management, particularly useful for non-operative fractures 6

Implementation by Care Level

Basic Level (Minimum Standard)

• Intravenous or rectal NSAIDs and/or paracetamol 2
• Local wound infiltration with long-acting local anesthetic 2
• Intravenous opioids (fentanyl or equivalent) in divided doses as needed 2

Intermediate Level

• Intravenous or rectal NSAIDs and paracetamol 2
• Ultrasound-guided peripheral nerve block (interscalene or suprascapular) with long-acting local anesthetic plus adjunct (clonidine) 2
• Intravenous opioids only if regional anesthesia contraindicated or unsuccessful 2

Advanced Level

• Intravenous NSAIDs and paracetamol 2
• Continuous peripheral nerve block with long-acting local anesthetic combined with clonidine 2
• Consider intraoperative ketamine or alpha-2 agonists for opioid-sparing effect 2
• Patient-controlled analgesia if continuous block not feasible 2

Critical Safety Considerations

Local Anesthetic Concentrations

Use low concentrations to minimize risk while maintaining efficacy 2:

• Bupivacaine or ropivacaine 0.1-0.25% for single-shot blocks 2
• 0.1% concentration for continuous nerve blocks 2
• Cautious use of adjuncts as they increase block density and duration 2

Monitoring Requirements

While compartment syndrome is rare in shoulder fractures (primarily a concern in lower extremity trauma), proper monitoring protocols should be in place 2:

• Acute pain service availability when using continuous blocks 2
• Regular pain assessments using age-appropriate tools 2
• Clear communication with surgical team about regional technique used 2

Evidence Supporting Nerve Blocks in Pediatric Fractures

Superior pain control: Nerve blocks provide clinically superior pain management compared to systemic opioids, with pain reduction of approximately 15-18% greater than morphine alone 7

Longer duration: Median analgesia duration with nerve blocks (313 minutes) significantly exceeds that of IV morphine (60 minutes) 7

Reduced opioid consumption: Nerve blocks effectively decrease opioid use and associated side effects like respiratory depression (21% with morphine vs 0% with nerve blocks) and vomiting 8, 7

Safety profile: No nerve block complications were reported in pediatric studies, while morphine groups experienced respiratory depression and other systemic effects 8, 7

Practical Implementation

Emergency Department Setting

• Nerve blocks should be considered early in the treatment pathway 2, 1
• Ultrasound-guided techniques are ideal for ED use where traditional nerve stimulator equipment may not be available 5
• Staff education and protocol development improve systematic pain management 2

Perioperative Setting

• Begin multimodal analgesia pre-operatively 3
• Critical: Continue regular NSAIDs and paracetamol after block resolution to prevent rebound pain 3, 4
• Perform blocks at anatomical sites distant from any active infection 4

Common Pitfalls to Avoid

• Inadequate post-block analgesia: Failure to provide scheduled non-opioids after regional block wears off leads to severe rebound pain 3, 4
• Delayed pain management: Pain control should begin immediately upon ED presentation, not delayed until definitive treatment 2, 1
• Age-related undertreatment: Younger children, especially neonates, are at highest risk of receiving inadequate analgesia 2, 9
• Relying solely on systemic opioids: This approach provides inferior pain control with more adverse effects compared to multimodal strategies 8, 7