NSAIDs in a Patient with Fractures?!

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The Issue

NSAIDs are excellent analgesics that can decrease the use of opiates for pain, but might lead to poor healing from orthopedic injuries.

Prior Evidence

In vitro studies and rat models since the early 80s showed delayed fracture healing with NSAIDs, and the effects appeared to be dose-related. These findings have been re-demonstrated in future in vitro and rat studies as well.   In humans however, the data has been, to say the least, mixed.  Multiple studies have been performed, with many types of orthopedic injuries and surgeries.  Some suggest that NSAIDs are associated with poor healing, while others suggest that there is no association. 

A comprehensive summary of studies done to this point can be found here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259713/table/tab4/. 

A significant amount of data exists regarding NSAIDs post-operatively for spinal fusion as well, with similarly mixed results: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259713/table/tab3/. 

Interestingly, one study has even suggested that narcotics might impair bone healing (Bhattacharyya, 2005). 

Current Guidelines

Not surprisingly, given the mixed results of studies to this point, guidelines regarding the use of NSAIDs for analgesia after fracture or spinal fusion do not exist, either in the orthopedic or emergency medicine literature.

The Problem

Because there are no guidelines, different groups of orthopedic surgeons will differ on what they prefer for their patients. (I can speak from experience – when I worked in Boston, the orthopedic surgery department had a firm stance against NSAID use)

Our Orthopedic department’s stance

After speaking with Dr. Brian Grawe and Dr. Archdeacon of our Orthopedic Surgery Department, for UCMC, NSAIDs are approved for the use of treatment of pain in all fractures except:

  • Tibia shaft fracture                                                                           
  • Humerus fracture
  • When treating non-unions of fractures
  • Surgeries including arthrodesis, fusions or osteotomies/ limb lengthening procedures
  • Spine fracture or spinal surgery

Again, this is institution-specific, but our Orthopedic Surgery Department agrees with the use of NSAIDs and feel that by giving NSAIDs, patients can minimize the use of opiates. In fact, they frequently use Toradol in the peri-op period. 

Bottom Line

Feel free to use NSAIDs in your patients with orthopedic injuries (fractures, sprains, etc), but do not use them in patients that have undergone spinal fusion in the previous six weeks, tibial shaft fractures, humerus fractures, non-unions, or in osteotomies (as outlined above).

Want to read more? Here’s a comprehensive review article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259713/

References

Bhattacharyya, T, Levin R, Vrahas MS, Solomon DH. (2005) Nonsteroidal antiinflammatory drugs and nonunion of humeral shaft fractures. Arthritis Rheum. Jun 15;53(3):364-7.

Ippokratis P, Theodora G, Calori, G, & Giannoudis, P.  Do Nonsteroidal Anti-Inflammatory Drugs Affect Bone Healing? A Critical Analysis. ScientificWorldJournal. 2012; 2012: 606404. Published online 2012 Jan 4. doi:  10.1100/2012/60640
 

Author: Sanjay Shewakramani, MD, Assistant Professor, University of Cincinnati Department of Emergency Medicine