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A single intra-articular injection of bupivacaine (0.25 percent) was more effective than either an intra-articular injection of ropivacaine (0.20 percent) or no injection in relieving postoperative pain for pediatric patients with closed supracondylar fractures.
Courtesy of Gaia Georgopoulos, MD

AAOS Now

Published 8/1/2011
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Mary Ann Porucznik

Bupivacaine effective for pain management of closed pediatric elbow fractures

Patients with supracondylar humerus fractures have less pain, narcotic use

“Supracondylar humerus fractures are the most common type of pediatric elbow fracture,” noted Gaia Georgopoulos, MD, of the Musculoskeletal Research Center at Children’s Hospital Denver. “Despite the frequency of this injury and surgical treatment, however, minimal attention has been paid to postoperative pain management.”

Dr. Georgopoulos and colleagues wanted to know whether an intra-articular injection of local anesthetic would be beneficial in relieving pain relief among pediatric patients with closed supracondylar humerus fractures who were treated with percutaneous pinning. She presented the results of their prospective, randomized, single-blinded (parent and child) trial at a single large tertiary pediatric hospital during the 2011 annual meeting of the Pediatric Orthopaedic Society of North America.

Patient selection
The study, which had institutional review board approval, included 124 patients, age 4 to 12 years, with closed type II (displaced with intact posterior cortex) or type III (displaced with no cortical contact) supracondylar humerus fractures treated at the hospital from June 2008 to August 2010. Patients who had open fractures, associated neurovascular compromise, fractures treated by open reduction, medical conditions that precluded the use of injected local anesthetic, or multiple injuries, and those unable to rank items in order (seriation task) or who weighed less than 14 kg (30 lb) were excluded.

Patients were blocked for randomization by age (4 to 7 years; 8 to 12 years) and assigned to receive no injection (control group, n = 43), a single bupivacaine injection (0.25 percent concentration) (n = 42), or a single ropivacaine injection (0.20 percent concentration) (n = 39). Presealed envelopes with the randomization were delivered to the attending surgeon as he or she entered the operating room.

All patients received standardized postoperative pain management and were sent home with the same oral pain medication (oxycodone and acetaminophen [0.1–0.15 mg/kg]). Analgesic medication administration was recorded preoperatively, intraoperatively, and postoperatively, with doses converted into morphine equivalents. Parents were asked to complete a take-home log, recording the use of prescription and over-the-counter analgesics in the first 72 hours post discharge.

Less pain, medication with bupivacaine
In addition to using a visual analog scale and a survey to measure pain, the researchers looked at the following outcome measures:

  • time to first narcotic administration
  • need for intravenous (IV) morphine and/or fentanyl injections
  • narcotic consumption in first 72 hours postoperatively
  • narcotic consumption across the study period
  • self-reported pain severity
  • parent-reported pain severity

“Only 10 percent of the patients in the bupivacaine group actually required IV narcotic while in the postanesthesia care unit (PACU), which was significantly different than both the control and the ropivacaine groups,” reported Dr. Georgopoulos. “The bupivacaine group also had significantly decreased pain medication requirements in the postoperative period while in the hospital and over the entire study period, compared to the control group.”

Researchers found no difference in IV narcotic use while in the PACU between the control and the ropivacaine groups and no difference between the bupivacaine and ropivacaine groups in terms of pain medication usage in the postoperative period while hospitalized and over the entire study period.

“When we looked at self-reported pain, we saw a tendency for the bupivacaine group to have lower pain scores, but this did not reach statistical significance. But when we looked at parent-reported pain severity, the bupivacaine group again had significantly lower pain scores than both the control group and the ropivacaine group, and there was no difference between the control and the ropivacaine groups,” said Dr. Georgopoulos.

She noted, however, that the medication log return rate was only 59 percent and that PACU nurses were not blinded to the study group designation.

“Compared to controls, the administration of intra-articular bupivacaine (0.25 percent) was associated with significantly increased time to first narcotic administration, decreased need for IV narcotics in the PACU, decreased total narcotic consumption, and decreased parent-reported pain. Compared to an intra-articular injection of ropivacaine (0.20 percent), an intra-articular injection of bupivacaine (0.25 percent) was associated with significantly increased time to first narcotic administration, decreased need for IV narcotics, and decreased parent-reported pain,” she concluded. “It’s a practice I would recommend to other surgeons.”

When asked about the impact of bupivacaine on articular cartilage, Dr. Georgopoulos noted that most of the reports on chondrolysis were associated with pain pumps, which bathe the cartilage in the local anesthetic. “With the single injection, I suspect that the synovium absorbs most of the bupivacaine rather quickly, and the cartilage is not exposed to the anesthetic for any length of time,” she said. “I have been doing this for probably 5 or 6 years and have never had a complication with it.”

Dr. Georgopoulos’ coauthors include Patrick Carry, BA; Zhaoxing Pan, PhD; Frank M. Chang, MD; Travis C. Heare, MD; Jason T. Rhodes, MD; Mark Hotchkiss, BA; Mark A. Erickson, MD; and Nancy Hadley Miller, MD.

Disclosure information: Dr. Erickson—Biomet; Dr. Miller—Spine, Scoliosis Research Society; Dr. Chang—no conflicts; Drs. Georgopoulos, Pan, Heare, and Rhodes, Mr. Carry, and Mr. Hotchkiss—no data.

Bottom Line

  • A prospective, randomized, single-blinded (parent and child) trial at a single large tertiary pediatric hospital measured the impact of a single intra-articular injection of bupivacaine, ropivacaine, or no injection on postoperative pain in patients with closed supracondylar fractures.
  • Researchers found that a single bupivacaine injection (0.25 percent) resulted in significantly increased time to first narcotic administration, decreased need for IV narcotics in the PACU, decreased total narcotic consumption, and decreased parent-reported pain compared to the control group.
  • Patients who received the bupivacaine injection reported less pain, and parent-reported pain was significantly less for patients who received bupivacaine than for those who received ropivacaine or no injection.