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Orthopedic extremity trauma – sprains,
strains, and fractures
CATHERINE A. MARCO AND JASON B. LESTER
n Agents
n Local anesthetics
n Acetaminophen
n NSAIDs
n Opioids
n Evidence
While mechanical approaches (e.g. splinting) are important in managing
sprain, strain, and fracture (SSF) pain, pharmacotherapy retains an
important position for orthopedic analgesia. Systemic analgesics used for
SSF include acetaminophen (paracetamol), NSAIDs, and opioids. Although
patients with severe pain or need for immediate relief should usually
be given IV analgesia, other routes may be indicated in the acute care
setting. 1
This chapter focuses on systemically active analgesics. Pain relief for SSF
can often be facilitated (or wholly provided) with local or regional injection
of local anesthetics. 2–9 The high number of potential uses for local anesthetics
in various SSF conditions precludes detailed discussion here, but ED
physicians should always think first of this approach. Examples of high utility
for local anesthetic injection include hip and radius fractures. 8–10 Evidence
from RCTs of femur fractures suggests superiority of local anesthetic injection
(for regional block) over morphine for managing pain in the ED. 10 The
local anesthetics are also useful in management of rib fractures (discussed
under chest wall trauma) and as adjuncts in ED procedural sedation and
analgesia (outside this text’s scope).
Acetaminophen (QID dose 650–1000 mg PO in adults, 15 mg/kg PO in
children) can be effective in controlling mild-to-moderate pain. One RCT in
patients with ankle sprains found acetaminophen (3900 mg daily) was not
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