Non-steroidal anti-inflammatory drugs in postoperative hand fracture management: Do they positively or negatively impact recovery?

Abstract

This editorial explores the impact of non-steroidal anti-inflammatory drugs (NSAIDs) on postoperative recovery in hand fracture patients, amidst shifting pain management strategies away from opioids due to their adverse effects. With hand fractures being significantly common and postoperative pain management crucial for recovery, the potential of NSAIDs offers a non-addictive pain control alternative. However, the controversy over NSAIDs' effects on bone healing—stemming from their Cyclooxygenase-2 inhibition and associated risks of fracture non-union or delayed union—necessitates further investigation. Despite a comprehensive literature search, the study finds a lack of specific research on NSAIDs in postoperative hand fracture management, highlighting an urgent need for future studies to balance their benefits against possible risks.

Key Words: Hand fracture, Post operative management, Non-steroidal anti-inflammatory drugs, Non-union, Bone healing, Cyclooxygenase-2 inhibitors, Opioid alternatives

Core Tip: Non-steroidal anti-inflammatory drugs (NSAIDs) present a non-addictive alternative to opioids, crucial amidst the opioid crisis. However, concerns about their impact on bone healing persist, particularly through Cyclooxygenase-2 inhibition. There is a need for dedicated research to balance NSAIDs' analgesic benefits against potential risks of fracture non-union or delayed union.

TO THE EDITOR

Hand fractures are the second most common type of fracture in the upper extremity[1]. Mastering their management includes providing exceptional longitudinal care, whether it be for cases managed conservatively or operatively. Often, emphasis is placed on pre- and intraoperative management techniques that can be used to optimize outcomes. However, uncontrolled pain in the postoperative period can negatively impact time to recovery, future hand function and quality of life while simultaneously increasing the risk of developing chronic pain.

Over the last several years, there has been a shift from using opioids for pain control due to the amount and significance of adverse effects, including addictive potential. Therefore, alternative options for pain control are necessary. It is important to sufficiently manage pain in postoperative hand fracture patients as the injuries and procedures are particularly painful. A patient in pain is less likely to comply with hand therapy and rehabilitation efforts, increasing the risk of future loss of mobility. One method of achieving post-operative pain control is using non-steroidal anti-inflammatory drugs (NSAIDs)[2].

The role of NSAIDs in the postoperative management of hand fractures is unclear; therefore, we sought to investigate the available data. By studying the effects of NSAIDs postoperatively on hand fracture healing and functional outcomes, evidence-based recommendations can be provided to inform practice. A comprehensive search of MEDLINE and EMBASE via Ovid was performed from inception to March 2023, which yielded 121 citations. After deduplication, 112 remained, only nine of which were considered relevant. None of these studies focused specifically on NSAIDs for postoperative pain control in hand fracture patients. Six studies examined the effects of NSAIDs on general bone healing, although two discussed animal models, and another included only non-surgical cases. Two studies focused on the role of NSAIDs in inhibiting bone healing. The final study examined NSAIDs as part of a multimodal regimen for pain control in distal radius fractures. No articles retrieved by the search met the inclusion criteria for this study; hand fractures, post-operative pain management, the use of NSAIDs, discussion of bone healing and non-union, and human subjects.

CLINICAL IMPLICATIONS

NSAIDs offer significant pain control without a risk of abuse, thus reducing pain without exacerbating the growing issue of opioid over-prescription and abuse[3]. While their analgesic effect has been extensively studied, there remains controversy regarding their impact on bone healing. This has stemmed from in vitro and animal studies demonstrating a delay in fracture healing attributed to the inhibition of Cyclooxygenase-2 (COX2) by NSAIDS. In fact, in COX2 knockout mice, there were fewer subjects with normal bone union as compared to both wild-type and COX1 knockouts[4]. Clinical studies have also shown an association between NSAID use for greater than three weeks and greater amounts of fracture non-union or delayed union (P = 0.001)[5].

CONCLUSION

This viewpoint highlights that there is a paucity of literature investigating the role of NSAIDs in the management of hand fractures, with the current knowledge stemming mostly from experimental data and retrospective studies in non-hand cases. There is an urgent need to conduct studies in the future to investigate whether the benefits of postoperative NSAIDs outweigh any potential risks. Given its high prevalence and its association with postoperative pain, gathering data on the effect of NSAIDs on post-fracture bone healing is valuable, insightful and critical in the current opioid climate.