Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association

Abstract

ObjectivesFracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established.MethodsClinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations.ResultsA total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use.ConclusionsIn patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.

Novel Techniques for Musculoskeletal Pain Management after Orthopedic Surgical Procedures: A Systematic Review

“…The reviewer thoroughly assessed the methodological quality and risk of bias of the 15 included studies [53][54][55][56][57][58][59][60][61][62][63][64][65][66][67] using a modified ROBVIS tool (Figure 2). Overall, the studies were well conducted, with low risk of bias ratings across most domains.…”

“…Outcome assessors were blinded in all the randomized trials, overcoming detection bias. Attrition and reporting bias were minimal, as most studies had complete outcome data and fully reported their pre-specified outcomes [53][54][55][56][57][58][59][60][61][62][63][64][65][66][67]. Overall judgments took these minor uncertainties into account, but the studies were still considered to have a reasonably low risk of bias.…”

“…These studies also strived to determine optimal pain management strategies. Murphy et al, (2023) [57] proposed peripheral nerve blocks as a potential strategy to decrease healthcare costs, opioid consumption, and related complications in acute orthopedic injury, offering specific treatment guidelines for improved pain management. However, the varied findings across these studies, such as the lack of significant differences in pain intensity reported in the study by Chen et al, (2015) [64] regarding music intervention, demonstrate the complexity and diverse nature of pain management outcomes.…”

Opioid-Sparing Nonsteroid Anti-inflammatory Drugs Protocol in Patients Undergoing Intramedullary Nailing of Tibial Shaft Fractures: A Randomized Control Trial

“…10 Murphy et al demonstrated that NSAIDs reduce post-trauma pain and the need for opioid administration while having minimal risk of fracture nonunion. 9 Similarly, McDonald et al found that adding ketorolac to the postoperative drug regimen markedly decreased opioid consumption after the management of ankle fractures. 11 Nonetheless, there is a lack of literature on NSAID use as an opioid-sparing pain control regimen after IMN of closed tibial shaft fractures.…”

“…7,8 In this context, NSAIDs present minimal risk to fracture healing and are a valuable option for perioperative pain control. 9 Furthermore, postoperative administration of NSAIDs leads to decreased opioid consumption and adequate pain control with few adverse effects in elective orthopaedic procedures. 10 Murphy et al demonstrated that NSAIDs reduce post-trauma pain and the need for opioid administration while having minimal risk of fracture nonunion.…”