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Pain Management of Musculoskeletal Injuries in Children: Current State and Future Directions

Ali, Samina MD, FRCPC, FAAP*; Drendel, Amy L. DO, MS; Kircher, Janeva BEng; Beno, Suzanne MD, FRCPC§

doi: 10.1097/PEC.0b013e3181e5c02b
CME Review Article
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Background: Pain is the most common reason for seeking health care in the Western world and is a contributing factor in up to 80% of all emergency department (ED) visits. In the pediatric emergency setting, musculoskeletal injuries are one of the most common painful presentations. Inadequate pain management during medical care, especially among very young children, can have numerous detrimental effects. No standard of care exists for the management of acute musculoskeletal injury-related pain in children. Within the ED setting, pain from such injuries has been repeatedly shown to be undertreated.

Objectives: Upon completion of this CME article, the reader should be better able to (1) distinguish multiple nonpharmacological techniques for minimizing and treating pain and anxiety in children with musculoskeletal injuries, (2) apply recent medical literature in deciding pharmacological strategies for the treatment of children with musculoskeletal injuries, and (3) interpret the basic principles of pharmacogenomics and how they relate to analgesic efficacy.

Results: Pediatric musculoskeletal injuries are both common and painful. There is growing evidence that, in addition to pharmacological therapy, nonpharmacological methods can be introduced to improve analgesia in the ED and after discharge. Traditionally, acetaminophen with codeine has been used to treat moderate orthopedic injury-related pain in children. Other oral opioids (hydrocodone, oxycodone) are gaining popularity, as well. Current data suggest that ibuprofen is at least as effective as acetaminophen-codeine and codeine alone. Medication compliance might be improved if adverse effects were minimized, and ibuprofen has been shown to have a similar or better adverse effect profile than the oral opioids to which it has been compared. Pharmacogenomic data show that nearly 50% of individuals have at least 1 reduced functioning allele resulting in suboptimal conversion of codeine to active analgesic, so it is not surprising that codeine analgesic efficacy is not optimal. At the same time, nonpharmacological therapies are emerging as commonly used treatment options by parents and adjuncts to analgesic medication. The efficacy and role of techniques (massage, music therapy, transcutaneous electrical nerve stimulation), although promising, require further clarification in the treatment of orthopedic injury pain.

Conclusions: There is a need to optimize the measurement, documentation, and treatment of pain in children. There is growing evidence that nonpharmacological methods can be introduced to improve analgesia in the ED, and efforts to help parents implement these methods at home might be advantageous to optimize outpatient treatment plans. In pharmacotherapy, ibuprofen has emerged as an appropriate first-line choice for mild-moderate orthopedic pain. Other oral opioids (hydrocodone, oxycodone) are gaining popularity over codeine, because of the current understanding of the pharmacogenomics of such medications.

*Associate Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada (Ali); †Assistant Professor (Drendel), Department of Pediatrics, Children's Hospitalof Wisconsin,Milwaukee, WI; ‡Medical Student (Kircher), School of Medicine, Queen's University, Kingston, Ontario; and §Assistant Professor (Beno), Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.

Reprints: Samina Ali, MD, FRCPC, FAAP, 2nd Floor, Rm. 7217A 11402, Aberhart Centre 1, University Avenue, Edmonton AB, Canada T6G 2J3 (e-mail: sali@)ualberta.ca).

The authors have disclosed that they have no significant relationship with or financial interests in any commercial companies that pertain to this educational activity.

All staff in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.

Lippincott CME Institute has identified and resolved all faculty conflicts of interest regarding this educational activity.

© 2010 Lippincott Williams & Wilkins, Inc.