What is the recommended approach for pain control in pediatric patients with shoulder fractures not requiring surgical intervention?

Pain Control for Pediatric Shoulder Fractures Managed Non-Operatively

For pediatric shoulder fractures not requiring surgery, implement a multimodal analgesic approach combining scheduled NSAIDs (preferably naproxen) or acetaminophen as baseline therapy, with opioids reserved for breakthrough pain, alongside non-pharmacological interventions including immobilization, environmental modifications, and distraction techniques. 1, 2

Pharmacological Management Algorithm

First-Line Baseline Therapy

• Administer scheduled NSAIDs or acetaminophen immediately upon diagnosis, not on an as-needed basis, to maintain consistent analgesia 2, 3
• Naproxen is the preferred NSAID due to its established efficacy and safety profile in children, with superior evidence compared to other NSAIDs 4
• Continue baseline non-opioid therapy throughout the acute pain period (typically 3-7 days for shoulder fractures) 2
• NSAIDs should be used judiciously but not withheld due to fear of rare adverse effects, as gastrointestinal, renal, and antiplatelet complications are uncommon in pediatric patients 5, 4

Breakthrough Pain Management

• Use oral opioids in divided doses only when baseline therapy is insufficient 2
• Opioids should be prescribed for short-term use (typically 3-5 days maximum) with clear instructions for tapering 1
• Studies demonstrate increased appropriate opiate use in children with fractures when pain is adequately assessed, but the goal remains opioid-sparing 1

Advanced Options for Severe Pain

• Consider regional anesthesia (nerve blocks) for severe refractory pain, even in the emergency department setting 2
• Ultrasound-guided peripheral nerve blocks with long-acting local anesthetic provide superior pain control with fewer systemic side effects 2
• For proximal humerus fractures specifically, interscalene or supraclavicular blocks may be appropriate when performed by experienced practitioners 2
• Low-concentration local anesthetics (bupivacaine or ropivacaine 0.1-0.25%) are safe and do not increase risk of compartment syndrome or delay diagnosis in children 1

Non-Pharmacological Interventions

Immobilization and Support

• Provide appropriate immobilization with a sling for comfort, recognizing that rigid casting is often unnecessary for many pediatric shoulder fractures 6
• Removable splints allow for hygiene and gradual mobilization as pain improves 6
• Consider kinesiotaping as an adjunct, which has demonstrated significant pain reduction (2.45 points on NRS) compared to standard treatment alone at 4 days post-injury 7

Environmental and Psychological Support

• Create a child-friendly, calming environment with colorful walls, ceiling pictures, and age-appropriate toys to minimize anxiety-related pain amplification 1
• Place children in private rooms when possible to reduce environmental stressors 1
• Implement distraction techniques appropriate to the child's age, as these are powerful anxiolytics that significantly reduce perceived pain 1, 5

Family-Centered Care

• Encourage parental presence and participation as "coaches" for cognitive behavioral strategies 1
• Educate parents about pain assessment and management expectations, as anxiety in parents can exacerbate the child's pain experience 1, 5
• Provide clear instructions for home pain management and red flags requiring re-evaluation 1

Pain Assessment Strategy

Systematic Monitoring

• Use age-appropriate validated pain scales at every clinical encounter: Numerical Rating Scale (NRS) for older children, revised FLACC scale for younger children, or Faces Pain Scale-Revised (FPS-R) 1, 3
• Implement a "Pain Passport" or similar patient-centered pain scoring tool, which has been shown to increase analgesic administration rates from 31% to 82.8% and reduce time to analgesia from 112 minutes to 24 minutes 8
• Assess pain before treatment, 15 minutes after intervention, and at follow-up (typically 3-4 days) 8, 7

Recognition of Inadequate Control

• In children, watch for the "three As" indicating inadequate analgesia: anxiety, agitation, and increased analgesic requirement 1
• Children may have difficulty articulating pain, requiring careful observation of behavioral cues 1

Critical Safety Considerations

Compartment Syndrome Vigilance

• While shoulder fractures carry lower compartment syndrome risk than forearm or tibial fractures, maintain clinical vigilance 1
• Regional anesthesia does not increase compartment syndrome risk or delay diagnosis when low-concentration local anesthetics are used with appropriate monitoring 1
• Normal compartment pressures in children (13-16 mmHg) are higher than adults, but clinical assessment remains the primary diagnostic tool 1

Common Pitfalls to Avoid

• Do not undertreat pain in children due to unfounded fears about medication side effects—this is now considered poor standard of care 3
• Avoid delaying analgesia while awaiting imaging or specialist consultation; pain control should begin immediately 1, 8
• Do not rely solely on "as-needed" dosing; scheduled baseline analgesia is more effective 2, 3
• Neonates and younger children are at highest risk of receiving inadequate analgesia and require particular attention 1

Follow-Up Protocol

• Schedule follow-up within 3-7 days with primary care provider or orthopedics as appropriate 6
• Continue baseline non-opioid analgesia even after acute pain improves to prevent rebound pain 2
• Many common pediatric shoulder fractures (including minimally displaced proximal humerus fractures and clavicle fractures) can be managed with minimal intervention and primary care follow-up rather than rigid orthopedic protocols 6