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324 Orthopedic extremity trauma
inferior to ibuprofen, but the NSAID dose was relatively low (1200 mg daily). 11
Acetaminophen’s main advantage is its relative safety in a broad range of
patient populations. Evidence from a variety of study populations supports its
employment as monotherapy (for mild pain) or as part of a combination
regimen for myriad types of SSF pain. 12–17 It is the preferred initial agent for
patients with pain that is not severe and who have contraindications for
NSAID therapy. 18 In some countries, acetaminophen has an additional
advantage of being available in an IV formulation (thus allowing patients to
stay nil by mouth).
The NSAIDs (e.g. ibuprofen 400–600 mg or 10 mg/kg PO QID, naproxen
500 mg PO BID, ketorolac 15–30 mg IV) are traditional mainstays of SSF
analgesia. This class is at least partly efficacious for SSF pain, and the
NSAIDs are superior to acetaminophen (or codeine) for monotherapy of
mild or moderate SSF pain. 19–21 The extensive clinical experience with
NSAIDs and SSF pain relief is not to be discounted. However, review of
evidence addressing NSAIDs for SSF indicates that the success of pain relief
with NSAIDs is tempered by safety concerns.
The safety issues with NSAIDs are a combination of “generic” problems (i.e.
those risks that are not related to SSF in particular) and SSF-specific problems.
The generic problems of GI and renal complications are important
owing to their relatively high likelihood in some SSF subgroups (e.g. elderly
patients with hip fractures).
The first of two SSF-specific NSAID safety issues is related to the effects of
this class on platelet function and hemostasis. Concerns about SSF-related
bleeding exacerbation by NSAIDs are at this time largely theoretical.
Nonetheless, absence of evidence addressing NSAID-associated SSF bleeding
should not completely allay concerns about using these analgesics in patients
with hematomas, or in those in whom operation may be necessary. Given the
prevalence of hematoma and intraoperative bleeding in the setting of SSF,
reports of ketorolac-induced operative bleeding in patients without SSF
should give pause to clinicians considering NSAID administration to patients
in whom bleeding could be problematic. 22
A second SSF-specific NSAID problem, fracture healing and nonunion, has
been addressed by studies, but the topic remains controversial as the data