Opioid Use
In the absence of sufficient evidence specific to distal radius fractures, it is the opinion of the workgroup that opioid sparing and multimodal pain management strategies should be considered for patients undergoing treatment for distal radius fractures.
Management of Distal Radius Fractures
This guideline was produced in collaboration with ASSH Endorsed by: AAHS, ASHT

Rationale

There have been very few studies directly comparing pain management regimens including opioids and opioid alternatives for the management of postoperative pain following treatment for distal radius fractures. In 2018, Luo et al examined the effectiveness of celecoxib vs. buprenorphine transdermal patch vs. codeine with ibuprofen. In this study, the authors examined pain at rest, daily activities, rehabilitation, and functional outcomes among 315 patients undergoing volar plate fixation for a distal radius fracture. The authors compared patients in the 2 weeks following surgery to 200 mg celecoxib twice per day (n=149), buprenorphine transdermal patch at 5 μg/h (n=89), and 13 mg codeine plus 200 mg ibuprofen twice per day (n=77), and followed outcomes for the 6 weeks following surgery. for pain management. The authors identified that functional outcomes as measured by the PRWE and DASH scores as well as range of motion among patients receiving celecoxib group were significantly lower at one month and three months compared with other groups. Pain at rest was similar across all groups and was mild. However, the authors noted patients receiving celecoxib had poorer pain management compared with the other groups during rehabilitation. The authors conclude that transdermal buprenorphine or codeine/ibuprofen should be considered for pain management during rehabilitation among patients with distal radius fractures undergoing volar plate fixation. However, this study was deemed low quality by the working group given methodologic gaps.

 

Despite the lack of evidence for the use of opioids or opioid alternatives among patients with a distal radius fracture, there is a growing body of evidence supporting opioid sparing and/or opioid free pain management options for other musculoskeletal conditions. Based on these studies and the risks of opioid analgesics (adverse events, misuse, opioid use disorder, diversion for nonmedical use), it is the recommendation of the committee that opioid alternatives (pharmacologic (local anesthetics, nonsteroidal anti-inflammatory agents, acetaminophen) and nonpharmacologic (ice, elevation, compression, cognitive therapies) should be considered alongside opioid sparing protocols when possible.

 

Risks of Implementation

Given the lack of evidence regarding effective pain management, failure to control post-injury and postoperative pain is a potential harm if pain is inadequately treated. Conversely, excess opioid prescribing is associated with greater opioid use, prolonged use, and the potential for misuse, opioid use disorders, and diversion to unintended users and nonmedical use. 

 

Future Research

Continued comparative studies are needed to compare the effectiveness of opioid analgesics and non-opioid pharmacologic and nonpharmacologic alternatives to determine the need for opioids, the dose and duration of therapy, and effective alternatives for pain management following distal radius fractures.


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