From the Guidelines
The use of NSAIDs with fractures is generally not recommended, especially in elderly patients, due to the potential adverse events such as acute kidney injury and gastrointestinal complications, and their potential to impair bone healing 1. When considering pain management for patients with fractures, it is essential to prioritize medications that do not interfere with the bone healing process.
- Acetaminophen is typically recommended for pain management, with a standard adult dose of 650-1000mg every 6 hours, not exceeding 4000mg per day.
- If pain is severe, opioid medications may be prescribed for short-term use, but with caution due to their potential for serious cardiovascular events, acute dyspeptic syndrome, and increased risk of respiratory failure 1.
- For unavoidable NSAID use, keeping the duration as short as possible (ideally less than 3-5 days) and using the lowest effective dose is advised, along with co-prescription of a proton pump inhibitor to mitigate potential gastrointestinal complications 1. Key considerations in pain management for patients with fractures include:
- Selecting medications that minimize negative effects on hemodynamic status, particularly in trauma patients 1.
- Using pain assessment tools, such as the numeric rating scale (NRS), verbal descriptor scale (VDS), faces pain scale (FPS), and visual analogue scale (VAS), to quantify pain intensity and guide treatment decisions 1.
- Being cautious with NSAID use in elderly patients due to their increased vulnerability to adverse events, such as acute kidney injury and gastrointestinal complications 1.
From the Research
NSAIDs and Fracture Healing
- The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with fractures is a topic of ongoing debate, with some studies suggesting that NSAIDs may interfere with bone healing 2, 3.
- However, other studies have found that NSAIDs can be beneficial in reducing pain and inflammation in patients with fractures, with a small effect on non-union 4.
- The efficacy and safety of NSAIDs for the treatment of acute pain after orthopedic trauma, including fractures, is not well established, but some studies suggest that they can be effective in reducing pain and the need for opioids 4, 5.
Benefits and Risks of NSAIDs
- NSAIDs have been shown to reduce post-trauma pain and the need for opioids in patients with traumatic fractures 4.
- However, there is also a risk of non-union associated with NSAID use, although this risk is small 4.
- Other potential risks associated with NSAID use include gastrointestinal bleeding, cardiovascular disease, and chronic renal disease 5.
Clinical Recommendations
- The Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures, as the benefit appears to outweigh the small potential risks 4.
- Acetaminophen and NSAIDs are first-line treatment options for most patients with acute mild to moderate pain, including those with fractures 5.
- Topical NSAIDs are recommended for non-low back, musculoskeletal injuries, including fractures 5.