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326 Orthopedic extremity trauma
There is some evidence comparing various PO opioid approaches, although
the studies directly comparing oral regimens are few. Hydrocodone (5–10 mg
PO) and oxycodone (5–10 mg PO) are commonly used and efficacious. 36
Hydrocodone is preferable to codeine for SSF pain, based on a combination
of efficacy and side effect profiles. 36 Hydrocodone and oxycodone (each in a
5 mg PO regimen, in combination with acetaminophen) are similarly safe and
efficacious for ED fracture treatment. 37 There is no difference between the two
agents at pain assessments at 30 or 60 min, and adverse effect profiles are
similar (although there may be higher incidence of subsequent constipation
after hydrocodone). 37
When combined with acetaminophen,themixed-mechanismopioid tramadol
is found to be equally efficacious to hydrocodone for relieving SSF pain. A
study of patients with ankle sprain and partial ligament tear found coadministered
tramadol (75 mg PO) with acetaminophen (650 mg PO) was equal in
terms of both efficacy and side effects to hydrocodone (7.5 mg PO) when the
following endpoints were assessed: pain relief magnitude during the first 4 h after
dosing, rate of 30% analgesic response, and rate of 50% analgesic response. 38
Many combination products are available. Such products often include an
opioid and a weaker analgesic such as acetaminophen or aspirin. There is no
reason to suspect that these combination products lack efficacy, but few
studies have rigorously evaluated their performance against alternative
approaches such as opioid monotherapy.
n Summary and recommendations
First line:
n consider local or regional anesthesia (e.g. using lidocaine)
n NSAID (e.g. ibuprofen 400–800 mg PO QID)
n opioid (e.g. morphine initial dose 4–6 mg IV, then titrate)
Reasonable: any NSAID or opioid
Pediatric:
n NSAID (e.g. ibuprofen 10 mg/kg PO QID)
n opioids (e.g. hydrocodone 2.5 mg PO q4–6h)