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Acetaminophen provides pain relief similar to narcotics after humerus fracture fixation
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SAN FRANCISCO — Acetaminophen is as effective as narcotic analgesics for control of postoperative pain among pediatric patients who undergo closed reduction and percutaneous pinning of displaced supracondylar humerus fractures fixation, according to the results of a recently presented study.
In their retrospective chart review, researchers from Philadelphia found no significant difference in postoperative pain between patients who received acetaminophen and codeine, acetaminophen and morphine or acetaminophen and a combination of codeine and morphine and those who had acetaminophen alone for pain management after fracture fixation.
“We had no complications in either group, so we cannot conclude from this study that acetaminophen is safer than other narcotic pain medications,” Christopher E. Swanson, MD, said during his presentation at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. “However, the senior author’s practices have shown historically less adverse events with the use of acetaminophen, namely less nausea, vomiting, sedation and decreased hospital stay. Acetaminophen, which is inherently associated with fewer side-effects, is as effective as narcotic analgesics at providing pain control after supracondylar fracture fixation.”
No difference in pain
The study included 217 pediatric patients with Gartland type II or III supracondylar humerus fractures who were treated between 2003 and 2009 at a single center. Patients had an average age of 5.5 years. Of the patients, 174 were treated with acetaminophen alone while 43 were treated with acetaminophen and narcotics.
Swanson and colleagues used the Face, Legs, Activity, Cry and Consolability (FLACC) scale to measure pain in patients younger than 5 years and the Oucher self-reporting scale for patients older than 5 years.
“Both of these were scored on a scale from zero to 10 and were reliant on what nurses had determined to be the appropriate score at that time,” Swanson said.
The mean postoperative pain score for the narcotic group was 2.2, while non-narcotic patients had a mean score of 1.9 pain. This difference was no statistically significant, Swanson said.
Fracture types, age-matching
When analyzing patients with type II fractures, the investigators found that patients treated with narcotics had a mean pain score of 1.2 and those in the non-narcotic group had a score of 1.9. In those with type III fractures, the narcotic group had a mean pain score of 2.5 vs. 1.9 for the non-narcotic group.
“We did notice that, in general, older patients tended to report or have higher pain scores reported by the nurses, and this was regardless of whether they were treated with narcotic or non-narcotic medications,” Swanson said.
An age-matched cohort of patients with type III fractures showed that the narcotic group had a mean pain score of 2.4 pain score vs. 2.1 for the non-narcotic group.
Swanson noted that possible limitations of the study include its retrospective design, reliance on nursing documentation and that the pain scales have both objective and subjective criteria. “There are also genetic differences amongst patients, and some patients are unable to convert codeine to its active metabolite,” Swanson said. – by Jeff Craven
Reference:
- Swanson CE, Chang K, Schleyer E, et al. Postoperative pain control in supracondylar humerus fracture fixation. Paper #226. Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.
For more information:
- Christopher E. Swanson, MD, can be reached at 214 N. 15th Street, Philadelphia, PA; email: ceswanson@gmail.com.
- Disclosure: Swanson has no relevant financial disclosures.
Perspective
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Jeffrey R. Sawyer, MD
The authors, who are from a high-volume children’s hospital, should be commended for their efforts to improve pain management for children who have sustained a supracondylar humerus fracture, the most common pediatric elbow fracture. They found no statistically significant differences in postoperative pain scores and complication rates between patients treated with morphine compared to those treated with acetaminophen, with no adverse reactions such as nausea and vomiting in the acetaminophen-treated patients. While not statistically significant, the pain scores were actually lower in the acetaminophen group than the narcotic group, even for completely displaced (Gartland type III) fractures.
The authors have shown that acetaminophen, which is inexpensive, readily available and well-tolerated, is as effective as narcotic medication in controlling postoperative pain in children surgically treated for supracondylar humerus fractures without the potential for narcotic-related side, effects.
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