Bela Delvadia, BS
Surena Namdari, MD, MS
Asif Ilyas, MD, MBA
SUMMARY POINTS:
Fractures represent common acute painful injuries that warrant deliberate evidenced-based pain management strategies.
Fractures are best managed with a multi-modal pain strategy that relies on non-opioid modalities and medications as the first line treatment, and reserves limited opioid use for breakthrough pain.
Fracture pain management strategies can be categorized into 3 groups: non-operative fractures, small bone fractures requiring operative repair, and large bone fractures requiring operative repair.
The use of other evidence-based pain management strategies such as regional nerve blocks, physical strategies, cognitive strategies, multimodal pharmaceutical strategies, and health care system strategies are also recommended to aid in pain management delivery.
INTRODUCTION
Due to the high incidence of fractures among all age groups, finding ways to adequately manage patients’ pain is necessary. The goal of fracture pain management is to provide adequate pain control while utilizing a multi-modal pain strategy with less reliance on opioids. Over the past 15 years, opioid prescription rates have increased threefold along with opioid-related overdose and death.1,2 Between 2006-2012, opioid prescription rates increased among providers with the goal of minimizing pain.3,4 Unfortunately, the increase in opioid prescriptions have not been associated with a reduction in patient reported pain, but has resulted in the increased incidence of opioid use disorder and opioid-related dependency and deaths.2
After a musculoskeletal injury, the recommended pain management strategy is based on the nature of the injury and/or procedure used in its treatment. For the purposes of pain management, Hsu et al. have recommended classifying fractures into three categories: non-operative injuries, minor injuries requiring operative fixation, and major injuries requiring operative fixation.2 In this analysis, we will slightly modify these three categories and update recommendations based on current evidence. The overall purpose of this analysis is to present recent data regarding pain management guidelines for acute fracture care relative to these three categories, as well as to highlight relevant evidence-based multi-modal pain management strategies for these acute injuries.
PRINCIPLES OF MUSCULOSKELETAL PAIN MANAGEMENT
Before diving into fracture-specific recommendations, certain pain management principles must be considered relative to musculoskeletal pain, adopted from the Pennsylvania Orthopaedic Society and updated to be most current and evidence-based.5
Non-opioid analgesics should be used as first line treatment of pain and are best utilized on a standing rather than as needed (PRN) basis. Specifically, utilizing acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) has been shown to be very effective in multi-modal pain management studies.2,6
If an opioid is prescribed, the lowest dose and shortest duration possible should be prescribed.7 The CDC recommends a maximum of 50 morphine milligram equivalents for most acute injuries for no more than 3-7 day.8 In addition, tramadol should be considered as a first line opioid agent as it has been shown to be equally efficacious as other stronger opioids with potentially less dependency risk.9,10
Prior to prescribing an opioid, counseling or education on safe opioid use should be delivered to the patient as counseling has been shown to decrease voluntary opioid use while maintaining high pain management satisfaction.11
NON-OPERATIVE FRACTURE
For non-operative management of a fracture or a similar traumatic injury – i.e., a distal radius (wrist) fracture or a metatarsal (foot) fracture, a multi-modal pain management strategy is recommended beginning with ice and elevation, maintenance medications in the form of acetaminophen 325mg or 500mg every 4-6 hours and a long-acting NSAID such as naproxen every 12 hours, followed by a low dose opioid for breakthrough pain. The recommended first line opioid for these fractures are 50 mg of tramadol every 4-6 hours for breakthrough pain.2 Alternatively, second line treatment includes 5mg of oxycodone.2 It is recommended that small prescriptions be given at a time, no more than 10 or 20 pill counts as larger amounts of opioids given can result in inadvertent excess use. The CDC recommends for acute injuries such as these non-operative fractures, that no more than 50 MME (equivalent to almost 6 pills of oxycodone 5mg) should be consumed per day, and typically for no more than 3 days with a maximum of 7 days should be needed or prescribed.8
OPERATIVE FRACTURE OF SMALL BONE
For fractures of small bones requiring operative repair – i.e., metacarpal (hand) fracture or a lateral malleolus (ankle) fracture, a multi-modal pain management strategy is again recommended. Post-operatively, rest, ice, and elevation is recommended. Medications begin with acetaminophen 500mg every 4-6 hours and a long-acting NSAID such as naproxen every 12 hours. For patients with a higher pain experience, gabapentin 100mg every 8 hours can also be added to the multi-modal standing pain regimen. Again, opioids are reserved for breakthrough pain, followed by a low dose opioid . First line opioid treatment can include oxycodone 5mg every 4-6 hours for breakthrough pain.2 As previously mentioned, it is recommended that small prescriptions be given at a time, with no more than 10 or 20 pill counts as larger amounts of opioids given can result in inadvertent excess use. Moreover, the CDC recommends for acute injuries and surgeries no more than 50 MME should be consumed per day, and typically no more than 3 days with a maximum of 7 days should be needed or prescribed.8 In contrast, the non-opioid multi-modal agents of acetaminophen, NSAIDs, and possibly gabapentin can be continued until 4 weeks post-operatively.
OPERATIVE FRACTURE OF LARGE BONE
For fractures of large bones requiring operative repair – such as femur (thigh or hip) fracture or tibia (leg) fracture, a multi-modal pain strategy including both opioid and non-opioid medications is recommended. Patients are scheduled to take acetaminophen 500mg every 4-6 hours, a long-acting NSAID such as naproxen or celecoxib every 12 hours, and gabapentin 100mg every 8 hours. In addition, oxycodone 5mg can be taken every 4-6 hours for breakthrough pain. Ideally, the opioid use is discontinued by 7 days post-operatively. However, the non-opioid multi-modal agents of acetaminophen, NSAIDs, and gabapentin can be continued until 4 weeks post-operatively.
OTHER CONSIDERATIONS
In addition to the pain medication strategies discussed above, other recommendations include the use of nerve blocks, physical strategies, cognitive strategies, multimodal pharmaceutical strategies, and health care system strategies.
The management of pain has different components pre-operatively, intraoperatively, and post-operatively. In the preoperative period, nerve blocks, specifically in hip fracture patients, have shown to reduce patient pain and opioid use postoperatively.12 Intraoperatively and immediately post-operatively, a local or regional block is also suggested, with emphasis on the use of a continuous catheter versus a single shot block to control pain.2,13 Data has shown local and regional blocks decrease pain and opioid use immediately and in the short-term perioperative period. Another study looking at the use of bupivacaine liposome, a long-acting local anesthetic, in wrist fractures found decreased opioid use and pain the day of surgery.14
Compared to other countries, patients who take opioids in the United States have greater pain and less satisfaction, suggesting psychological factors play a role in the perception of pain.15 Some cognitive and emotional strategies to reduce pain include discussing expected pain and recovery with patients in advance. Research has also suggested patients with preexisting conditions such as anxiety, depression, or posttraumatic stress disorder are more likely to have higher pain intensity.2 Connecting these patients to psychosocial interventions early on may help with post-operative pain control.
Some physical modalities suggested to help with pain management postoperatively include transcutaneous electrical nerve stimulation (TENS), immobilization, and cold therapy. TENS helps reduce pain by applying electrical stimulation to peripheral nerves.12 Recommendations on TENS are not strong due to moderate quality evidence, but overall have been found to be effective in conjunction with other post-operative pain control methods.16 Additionally, while there is mixed literature results on cold therapy, it is recommended as an adjunct to other post-operative managements.2 However, there is still limited evidence on the best delivery method.
Lastly, a health care system strategy to help with pain management is the Prescription Drug Monitoring Program (PDMP). Providers should register with their state’s PDMP and check it before prescribing opioids to patients. This allows providers to learn more about a patient's history of opioid use and therefore avoid overprescribing.
CONCLUSION
Pain management after acute injuries such as fractures, is a common problem that is best managed using evidenced-based multi-modal pain management strategies with the goal of providing good pain relief for the injured patient, while avoiding inadvertent harm from opioid dependency. The pain management strategy can be categorized by severity, but should rely on non-opioid modalities and analgesics as first line treatment while utilizing opioids sparingly for breakthrough pain.
References:
1. Sun, EC, Dixit, A, Humphreys, K, Darnall, BD, Baker, LC, Mackey, S: Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ 2017;356:j760.
2. Hsu, JR, Mir, H, Wally, MK, Seymour, RB, the Orthopaedic Trauma Association Musculoskeletal Pain Task Force: Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. Journal of Orthopaedic Trauma 2019;33:e158–e182.
3. Kim, N, Matzon, JL, Abboudi, J, Jones, C, Kirkpatrick, W, Leinberry, CF, Liss, FE, Lutsky, KF, Wang, ML, Maltenfort, M, et al.: A Prospective Evaluation of Opioid Utilization After Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines. J Bone Joint Surg Am 2016;98:e89.
4. Saini, S, McDonald, EL, Shakked, R, Nicholson, K, Rogero, R, Chapter, M, Winters, BS, Pedowitz, DI, Raikin, SM, Daniel, JN: Prospective Evaluation of Utilization Patterns and Prescribing Guidelines of Opioid Consumption Following Orthopedic Foot and Ankle Surgery. Foot Ankle Int 2018;39:1257–1265.
5. Pennsylvania Orthopaedic Society: Opioid recommendations for acute pain. at <https://www.paorthosociety.org/resources/ Documents/POS%20Opioid%20Statement%20and% 20Recommendations%20Final.pdf>.
6. Labrum, JT, Ilyas, AM: The Opioid Epidemic: Postoperative Pain Management Strategies in Orthopaedics. JBJS Rev 2017;5:e14.
7. Helmerhorst, GTT, Vranceanu, A-M, Vrahas, M, Smith, M, Ring, D: Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am 2014;96:495–499.
8. Centers for Disease Control and Prevention: Guideline for prescribing opioids for chronic pain. at <https://www.cdc.gov/drugoverdose/pdf/prescribing/Guidelines_Factsheet-a.pdf>.
9. Dart, RC, Iwanicki, JL, Black, JC, Olsen, HA, Severtson, SG: Measuring prescription opioid misuse and its consequences. Br J Clin Pharmacol 2021;87:1647–1653.
10. Miller, A, Kim, N, Zmistowski, B, Ilyas, AM, Matzon, JL: Postoperative Pain Management Following Carpal Tunnel Release: A Prospective Cohort Evaluation. Hand (N Y) 2017;12:541–545.
11. Ilyas, AM, Chapman, T, Zmistowski, B, Sandrowski, K, Graham, J, Hammoud, S: The Effect of Preoperative Opioid Education on Opioid Consumption After Outpatient Orthopedic Surgery: A Prospective Randomized Trial. Orthopedics 2021;44:123–127.
12. Sanzone, AG: Current Challenges in Pain Management in Hip Fracture Patients. Journal of Orthopaedic Trauma 2016;30:S1–S5.
13. Moucha, CS, Weiser, MC, Levin, EJ: Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty: Journal of the American Academy of Orthopaedic Surgeons 2016;24:60–73.
14. Alter, TH, Liss, FE, Ilyas, AM: A Prospective Randomized Study Comparing Bupivacaine Hydrochloride Versus Bupivacaine Liposome for Pain Management After Distal Radius Fracture Repair Surgery. J Hand Surg Am 2017;42:1003–1008.
15. Nota, SPFT, Spit, SA, Voskuyl, T, Bot, AGJ, Hageman, MGJS, Ring, D: Opioid Use, Satisfaction, and Pain Intensity After Orthopedic Surgery. Psychosomatics 2015;56:479–485.
16. Chou, R, Gordon, DB, de Leon-Casasola, OA, Rosenberg, JM, Bickler, S, Brennan, T, Carter, T, Cassidy, CL, Chittenden, EH, Degenhardt, E, et al.: Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The Journal of Pain 2016;17:131–157.