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. 2014 Sep;60(9):817.

Fracture healing and NSAIDs

Ian C Taylor 1, Adrienne J Lindblad 2, Michael R Kolber 3
PMCID: PMC4162697  PMID: 25217677

Clinical question

Do nonsteroidal anti-inflammatory drugs (NSAIDs) increase risk of fracture nonunion or impede healing?

Bottom line

Limited RCT data suggest NSAIDs do not impair fracture healing. Cohort studies associating NSAIDs with fracture nonunion are likely showing that patients with nonhealing (painful) fractures use more analgesics. As NSAIDs provide pain relief equivalent or superior to other analgesics, often with fewer side effects, patients should not be denied their short-term use for fractures.

Evidence

  • Adults—2 RCTs (N = 140) of predominantly middle-aged women with Colles fractures randomized to flurbiprofen (14 days)1 or piroxicam (20 mg/d for 8 weeks)2 versus placebo:

    • -No difference in recovery time, physiotherapy needs, malunion or nonunion,1 functional recovery, or healing.2

    • -Superior pain relief with NSAIDs (both trial arms allowed acetaminophen if required).

    • -Limitations: about 20% lost to follow-up; small numbers.

  • Children—1 RCT (N = 336)3 of children with arm fractures randomized to ibuprofen or acetaminophen and codeine:

    • -No difference in fracture nonunion at 1 year.

    • -Ibuprofen provided equivalent pain relief with less functional impairment and fewer adverse effects.

  • Quasi-RCT of adults with acetabular fractures requiring heterotopic ossification prophylaxis4 is misleading. Patients with less-serious injuries and different surgical approach (not randomized to NSAIDs or radiation for prophylaxis) were analyzed in the “non-NSAID” arm.

Context

  • Retrospective cohort and case-control studies associating NSAIDs with nonunion5–8 are confounded by differing injuries,7 smoking rates,7,8 and treatments.8 They demonstrate association, not causation.6 Opioid use is also associated with nonunion. Patients with nonhealing (painful) fractures are probably just more likely to use analgesics.

  • Rate of nonunion of long-bone fractures is 1% to 6%.5–7

  • NSAIDs provide good postsurgical pain relief in adults,9 and are superior to acetaminophen or codeine and equivalent to acetaminophen plus codeine (with fewer adverse events) for pediatric musculoskeletal injury.10

  • Some animal studies demonstrate that supranormal doses of NSAIDs impair bone healing.11,12

Implementation

Appropriate pharmacologic and nonpharmacologic (splints or fracture reduction) treatment for patients with painful fractures should be a priority in all emergency departments. Some patients (especially children) with fractures have analgesia unnecessarily delayed13 or do not receive analgesia in the emergency departments.14 Preventing fractures is obviously ideal, but when they do occur, patients should not be denied NSAIDs for short-term pain relief.

Tools for Practice articles in Canadian Family Physician (CFP) are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in CFP are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice@cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

This article is eligible for Mainpro-M1 credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.

La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de septembre 2014 à la page e439.

References

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