Fracture Fridays: NSAIDs for patients with fractures – Do they delay healing?

The case

A kid breaks a bone and you splint it and they feel better. It still hurts some and you are wondering if prescribing ibuprofen will delay healing because of something you remembered in medical school.

Discussion

You may have heard (correctly) that NSAIDs are great for broken bones and that we should avoid excessive prescribing of opiates. We know that inflammatory processes are important early on when bones are healing from a fracture and in theory NSAIDs may delay this, based primarily on animal data. Unfortunately the evidence is far from comprehensive, but here are three studies that attempt to get at the aforementioned question.

Davis TR and Ackroyd CE. Non-steroidal anti-inflammatory agents in the management of Colles’ fractures. Brit J Clin Prac 1988;42(5):184-9.

An adult RCT study with high drop out rate involving 100 patients >40 years old with a 1st Colles’ fracture given flurbiprofen 50/100mg or placebo. Suggested that a small proportion of patients had early delay in healing, but none with delayed healing at one year

Adolphson P, Abbaszadegan H, Jonsson U et al. No effects of piroxicam on osteopenia and recovery after Colles’ fracture. Arch Orthop Trauma Surg.1993:112(3):127-30.

This small study of 42 post menopausal women with first Colles’ fracture given piroxicam 20mg or placebo showed no difference in recovery rate. The randomization process was not well spelled out and the two groups were different from a demographic standpoint.

Giannoudis PV, MacDonald DA, Matthews SJ, Smith RM, Furlong AJ, and De Boer P. Nonunion of the femoral diaphysis: the influence of reaming and non-steroidal anti-inflammatory drugs J Bone Joint Surg (Br). 2000; 82; 655-658.

A case-control study of 99 patients that had an intramedullary nail placed for a femur fracture. Phone followed revealed a significant difference in NSAID use between the non-union (62.5%) and successful healing (13.4%0 groups (p<0.0001). The non-union group tended to use NSAIDs for longer (21 weeks vs 1 week). There was no matching data on the cases and controls

What do these studies have in common? They have nothing to do with kids! OK, so try this one on for size.

Drendel et al. A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain Ann Emerg Med. 2009;54(4):553. Epub 2009 Aug 19.

This double blinded RCT of children during the first 3 days after discharge from the ED given either ibuprofen of acetaminophen with codeine. The authors noted that the “proportion of treatment failures for ibuprofen (20.3%) was lower than for acetaminophen with codeine (31.0%), though not statistically significant (difference=10.7%; 95% confidence interval -0.2 to 21.6).” They also noted that the proportion of kids with pain while at play, sleep, eating or school was significantly lower for the ibuprofen group. More children in the acetaminophen with codeine group reported adverse effects. The authors concluded (for a number of reasons) that ibuprofen should be recommended/prescribed over acetaminophen with codeine. However the study did not address non-union. 

OK, so there isn’t good evidence one way or the other. It is important to note that there is no conclusive evidence one way or the other. Another study from Clark et al in PEDIATRICS in 2007 randomized musculoskeletal injures to tylenol, ibuprofen or codeine. Ibuprofen won out there as well.

So, when discharging a child with a fracture home from the Emergency Department feel free to recommend ibuprofen and know that it is the best choice for pain management, and as far as we know, won’t increase the risk of non-union or delay healing.

References

By |2018-08-30T15:55:35+00:00August 31st, 2018|Fracture Fridays, Orthopedics|

About the Author:

Brad Sobolewski, MD, MEd is an Associate Professor of Pediatric Emergency Medicine and an Assistant Director for the Pediatric Residency Training Program at Cincinnati Children's Hospital Medical Center. He is on Twitter @PEMTweets and authors the Pediatric Emergency Medicine site PEMBlog. All views are strictly my own and not official medical advice.