What is the intravenous (IV) pain management for a complicated humeral fracture?

From the Guidelines

For IV pain management of a complicated humeral fracture, I strongly recommend starting with intravenous morphine titration, as it has been shown to be efficient in 82% of cases in the emergency department 1. This approach is supported by the guidelines for the acute care of severe limb trauma patients, which emphasize the importance of protocolization in technique efficiency 1. The use of a loading dose of morphine is not compulsory, and multimodal analgesia, which combines drugs and/or techniques with different and synergistic pathways, can improve analgesia and reduce the risk of dose-dependent side effects associated with opioids 1. Some key points to consider when managing pain in this context include:

• The use of paracetamol and morphine, which have an additive interaction, to improve analgesia 1
• The addition of low-dose ketamine, which can improve analgesia and reduce the required morphine dose 1
• The potential use of locoregional anaesthesia, such as femoral block, which can be effective in emergency medicine context, particularly in the out-of-hospital setting 1
• The importance of multimodal analgesia in decreasing the intensity of acute pain and limiting the use of opioids, which can contribute to the sustainability of pain 1 It is also important to note that the phenomenon by which acute pain becomes chronic is still poorly understood, and no study has shown the value of a particular management to reduce the risk of chronic pain in this context 1. However, the use of low-dose ketamine given perioperatively has been associated with reduced risk of chronic pain after surgery 1. Overall, a multimodal approach to pain management, including intravenous morphine titration, multimodal analgesia, and locoregional anaesthesia, can provide effective pain relief for patients with complicated humeral fractures.

From the FDA Drug Label

The usual starting dose in adults is 0.1 mg to 0.2 mg per kg every 4 hours as needed to manage pain. Administer the injection slowly. Individualize treatment in every case, using non-opioid analgesics, opioids on an as needed basis and/or combination products, and chronic opioid therapy in a progressive plan of pain management The dose should be adjusted according to the severity of pain, the occurrence of adverse events, as well as the patient’s underlying disease, age, and size.

For IV pain management of a complicated humeral fracture, the recommended starting dose of morphine is 0.1 mg to 0.2 mg per kg every 4 hours as needed. The dose should be adjusted according to the severity of pain and the patient's individual characteristics, and administered slowly 2, 2.

From the Research

IV Pain Management for Complicated Humeral Fracture

• The management of proximal humerus fractures is a complex issue, with various treatment modalities available, including nonoperative and operative approaches 3, 4.
• The main goals of treatment for proximal humerus fractures include restoration of function, pain relief, and prevention of complications such as prolonged healing or non-healing and avascular necrosis 3.
• Patient and fracture factors can predict opioid dependence following upper extremity fractures, with preoperative opioid dependence and fracture complexity being significant risk factors for postoperative narcotic dependence 5.
• Effective analgesic treatment should be initiated rapidly in the prehospital setting to alleviate stress and improve quality of care, with intravenous fentanyl being a commonly used option 6.
• In the acute pediatric pain setting, intravenous acetaminophen has been shown to be compatible with morphine, fentanyl, and ketamine, allowing for concurrent administration in concentrations commonly used in pediatric patients 7.

Treatment Options

• Nonoperative treatment strategies, such as conservative management, may be suitable for certain types of proximal humerus fractures 3, 4.
• Operative treatment strategies, including open reduction and internal fixation, may be necessary for more complex fractures or those with significant displacement 3, 4.
• The use of opioid analgesics, such as morphine and fentanyl, may be necessary for pain management, but should be used cautiously due to the risk of dependence 5, 6.
• Alternative pain management options, such as intravenous acetaminophen, may be considered in conjunction with opioid analgesics to reduce the risk of dependence and improve pain control 7.

Risk Factors for Opioid Dependence

• Preoperative opioid dependence is a significant risk factor for postoperative narcotic dependence, with a 2.42 times increased risk 5.
• Fracture complexity, such as complex 3- and 4-part fractures, is also a risk factor for postoperative dependence, with a 1.93 times increased risk 5.
• Other factors, such as age, gender, and comorbidities, may also influence the risk of opioid dependence, but were not found to be significant in the study 5.