In Children with Uncomplicated Extremity Fractures, Oral Ibuprofen is as Effective as Oral Morphine for Pain Reduction and has Fewer Adverse Events

EBM Focus - Volume 10, Issue 3

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Reference: CMAJ 2014 Dec 9;186(18):1358 (level 1 [likely reliable] evidence)

Extremity fractures are common and often painful injuries in children presenting to the emergency department. Most children report the highest level of pain at the time of the injury or within 48 hours of injury (Pediatr Emerg Care 2006 Feb;22(2):94) and inadequate pain management may increase healing time (Pediatr Emerg Care 2010 Jul;26(7):518). Concerns about prescribing opioids have left physicians looking for other options for pain management. A recent randomized trial compared oral ibuprofen vs. morphine every 6 hours as needed for 24 hours after discharge in 183 children presenting to the emergency department with uncomplicated extremity fractures. All children were also allowed to take acetaminophen for breakthrough pain.

Children in the trial had fractures of the radius, ulna, clavicle, humerus, elbow, forearm, tibia, or fibula. Children not experiencing pain severe enough to use an analgesic were excluded from the analysis and this represented 26.8% of the children with fractures. Pain was assessed immediately before and 30 minutes after each analgesic dose using the Revised Faces Pain Scale with a range of 0-5 (a higher score indicates more severe pain). The median pain score at discharge was 2. All analgesic doses achieved a pain reduction greater than the minimal clinically important difference of 1 point. There was no significant difference in pain reduction comparing morphine vs. ibuprofen, and no significant difference between groups in the percentage of patients requiring acetaminophen for breakthrough pain. Morphine was also associated with an increase in adverse events compared to ibuprofen (56.1% vs. 30.9%, p < 0.01 NNH 4). Most commonly reported adverse events included nausea, vomiting, and drowsiness.

The results of this trial indicate that over-the-counter ibuprofen is as effective for pain relief as morphine and has fewer adverse events. There are some limitations to the design of the study which are worth noting. The timing of pain assessment is fine for ibuprofen, but narcotics such as morphine often lose their effectiveness after 4 hours and so checking a before dose pain level at 6 hours may not represent the optimal degree of effectiveness. Nonetheless, given the increased rate of adverse effects as well as the more widespread problem of prescription opioid abuse (often diverted from pills prescribed for appropriate indications and not used), knowing that ibuprofen will give comparable pain relief can be reassuring to prescribers who do not want patients to have untreated pain. One additional consideration about this trial relates to the issue of NSAID safety. NSAIDs inhibit bone healing in animal models and have been associated with nonunion and malunion in some studies of fractures in adults (typically fractures requiring surgical repair) (J Trauma Acute Care Surg. 2014 Mar;76(3):779, Acta Orthop. 2012 Dec;83(6):653, Curr Opin Rheumatol. 2013 Jul;25(4):524). However, studies of non-complicated bone fractures in children demonstrate no significant relationship between NSAIDs and bone healing or functional outcomes (J Pediatr Orthop. 2010 Oct-Nov;30(7):655, Ann Emerg Med. 2009 Oct;54(4):553, Can Fam Physician. 2014 Sep;60(9):817). In summary, for children with uncomplicated extremity fracture, ibuprofen may provide safe and effective pain relief thereby limiting the use of opioids.

For more information, see the Tibial plateau fracture, Clavicular fracture, Buckle fracture of distal radius, and Distal radius fracture topics in DynaMed.