Is a benzodiazepine (BZD) commonly prescribed as a first-line treatment for a patient with a greater tuberosity fracture?

Benzodiazepines Are Not Commonly Prescribed for Greater Tuberosity Fractures

Benzodiazepines should not be prescribed as first-line treatment for greater tuberosity fractures, as they address anxiety rather than pain, significantly increase fracture risk, and have no role in the standard analgesic management of orthopedic injuries.

Why Benzodiazepines Are Inappropriate

They Don't Treat Pain

• Benzodiazepines reduce anxiety, not pain, making them fundamentally unsuitable for managing orthopedic trauma 1
• The mechanism of benzodiazepines involves GABA receptor modulation for anxiolysis, with no analgesic properties 1

They Increase Fracture Risk

• Benzodiazepine use increases fracture risk by 50-110% in adults, with adjusted odds ratios ranging from 1.39 to 1.46 during active treatment periods 2, 3
• The risk is highest during the first 4 weeks of new benzodiazepine use (adjusted IRR 1.46,95% CI 1.28-1.66), precisely when a greater tuberosity fracture patient would be most vulnerable 2
• This increased fracture risk applies to both elderly and non-elderly adults, regardless of whether short-acting or long-acting formulations are used 2

They Cause Dangerous Side Effects in Fracture Patients

• Benzodiazepines are associated with reduced mobility, decline of functional independence, falls, and injuries—all catastrophic outcomes for someone with an existing fracture 4
• In patients with advanced cirrhosis (relevant for hepatocellular carcinoma management), benzodiazepines carry such high risk of falls and altered mental status that guidelines recommend "great caution" even for psychological distress 1
• Patients prescribed benzodiazepines cannot drive afterward and require someone to take them home, creating practical barriers to care 1

Evidence-Based Analgesic Approach for Greater Tuberosity Fractures

First-Line: Acetaminophen

• Acetaminophen 1000 mg every 6 hours is mandatory baseline treatment, significantly decreasing supplementary opioid requirements 5
• This can be administered up to 3 g/day for mild-to-moderate pain 1

Second-Line: Regional Anesthesia

• Regional nerve blocks (femoral nerve block or fascia iliaca compartment block) provide superior pain control with fewer side effects compared to systemic medications for proximal extremity fractures 5

Third-Line: Opioids for Breakthrough Pain

• Oxycodone immediate-release should be reserved strictly for breakthrough pain unresponsive to acetaminophen and regional techniques 6
• Standard dosing is 5 mg every 4-6 hours as needed, with 50% dose reduction if renal impairment exists 5

NSAIDs: Use With Caution

• NSAIDs are relatively contraindicated until renal function has been confirmed adequate, as approximately 40% of fracture patients have moderate renal dysfunction 5
• When used, NSAIDs require gastroprotective agents due to 2.70-5.36 times increased risk of GI bleeding 6

Common Clinical Pitfall

The most dangerous error is prescribing benzodiazepines to manage the anxiety that naturally accompanies acute fracture pain. This approach:

• Fails to address the actual pain 1
• Increases the patient's risk of sustaining additional fractures by 50-110% 2, 3
• Impairs mobility and functional recovery 4
• Creates sedation that prevents the patient from safely leaving the clinical setting 1

Standard Treatment for Greater Tuberosity Fractures

• Minimally displaced fractures (<3 mm) are treated with a three-phase rehabilitation protocol: immobilization in a sling for 3 weeks, followed by pendular and active-assisted exercises at 3-6 weeks, then active exercises starting at 6 weeks 7
• Displaced fractures (>3-5 mm) require surgical intervention to prevent subacromial impingement and rotator cuff dysfunction 8
• Pain management follows the acetaminophen-first, regional-anesthesia-second, opioid-third algorithm described above 5, 6

Benzodiazepines have no role in this treatment pathway and would actively harm the patient's recovery.