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Reference: Ann Emerg Med 2009 Oct;54(4):553, (level 2 [mid-level] evidence)
A six year old boy was playing on the monkey bars at school. He suddenly lost his grip and fell to the ground on his outstretched right hand from a height of about four feet. Now he has pain in his distal right forearm and painful movement of his right wrist. His mother was called, and he was brought to the emergency department for evaluation. Plain x-rays of the right forearm showed a buckle fracture. The child is in moderate distress from pain. What is the best option for outpatient analgesia for this child?
To determine the most effective and safe method of outpatient analgesia for a pediatric arm fracture that did not need reduction, a double-blind, multi-dose clinical trial was reviewed. 336 children between the ages of 4 to 18 years who weighed less than 60 kg and had an arm fracture were randomized to ibuprofen (10mg/kg) or acetaminophen plus codeine (1mg/kg of the codeine component) during the first 3 days after discharge from the emergency department. The primary outcome was failure of the assigned medication to provide adequate pain relief leading to use of a rescue medication. There was adequately described randomization and double blinding, however allocation concealment was unclear. Functional outcomes, adverse effects and parent satisfaction were assessed at 72 hours, one year, and up to four years.
Failure to provide adequate pain relief for ibuprofen was 20.3% compared to the acetaminophen plus codeine group at 31%, but these findings were not statistically significant (difference 10.7%, 95% CI -0.2% to 21.6%). Children taking ibuprofen had better functional outcomes which included measurements of problems with play, eating, sleep, and school (p values and confidence intervals were not reported). The acetaminophen plus codeine group had significantly higher adverse effects at 50.9% compared to 29.5% in the ibuprofen group (difference 17.8%, 95% CI 9.1%-33.7%). Parent satisfaction rates with ibuprofen were 85.8% compared to 67.3% with acetaminophen plus codeine (difference 18.5%, 95% CI 7.3%-29.6%).
The study had some limitations including follow-up less than 80%, pain medication given by parents and not in a controlled manner, and data was gathered by parent diaries or telephone reports. The authors stated that there was no placebo control group because it was felt to be unethical to deny patients some form of analgesia. There has been speculation that NSAIDs could reduce fracture healing in young children, but this is unproven. This study’s authors did not find evidence of reduced healing at one year.
Based on this study, ibuprofen appears at least as effective as acetaminophen plus codeine for pain relief in children with arm fracture, and may be associated with better functional outcomes, fewer adverse events, and better parent satisfaction.
Reference: Drendel AL, Gorelick MH, Weisman SJ, Lyon R, Brousseau DC, Kim MK. A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain. Annals of Emergency Medicine. 2009 Oct; 54(4): 553-60.
For more information, see Buckle fracture of distal radius in DynaMed.