Case: A 24 year old male with no past medical history presents with a closed distal radius and ulna fracture after a cycling accident. After closed reduction and splinting, his pain is much improved. You tell him that he will be discharged with oxycodone for pain as needed, but he asks if he can just take ibuprofen because oxycodone and other opioids make him sleepy, and he needs to return to work tomorrow.
Clinical Question: Should patients with acute fractures avoid NSAIDs?
Extremity fractures are relatively common presentations in the ED. Recent literature from the orthopedic world has suggested that usage of NSAIDs (non-steroidal anti-inflammatory drugs) in the setting of acute fractures hinders the healing process and leads to worse outcomes. Given that we often try to provide non-narcotic methods to control pain in the ED, removing a whole class of drugs like NSAIDs should not be done without strong evidence that they result in poorer outcomes for patients.
A paper published in the Journal of Bone and Mineral Research in 2002 treated rats with a COX-2 (cyclo-oxygenase 2) selective NSAID, then studied signs of healing based on radiologic, histologic, and mechanical measures. The authors showed that endochondral ossification was markedly deficient in both rats treated with a COX-2 inhibitor, suggesting that pro-inflammatory prostaglandins (suppressed by COX-2 inhibitors) are necessary for normal fracture healing. Similarly, fracture healing is impaired in mice that have a mutation in the COX-2 gene . A recent systematic review of the existing data published in the Journal of Bone and Joint Surgery in 2012 found similar results. This review included 316 relevant papers, and concluded that the preponderance of evidence showed that inhibiting COX-2 disrupted early fracture healing in multiple animal models, although in vivo studies in humans have not yet substantiated this finding. A limitation of the review was that the majority of the studies were small and of variable quality with numerous potentially confounding variables. Nevertheless, the authors concede that a short term course of NSAIDs in the setting of acute fracture is likely safe and may not impede healing to a significant degree . Larger and more robust human studies are needed to better delineate the effects of NSAIDs on fracture healing and patient-oriented outcomes, but a single dose of NSAIDs may be acceptable in patients who should avoid opioid analgesics.
Submitted by Jarrod Dornfeld, PGY-2
Edited by Phil Chan (@PhilChanEM), PGY-4
Faculty Reviewed by Albert Kim, MD, MACM