Ibuprofen Best for Acute Traumatic Musculoskeletal Injuries
By Kathleen A. Haines, MD
Clark E, Plint AC, Correll R, Gaboury I, Passi B. A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics. 2007; 119(3):460-467.
Objective: The authors’ goal was to determine which of three analgesics—acetaminophen, ibuprofen, or codeine—given as a single dose, provides the most efficacious analgesia for children presenting to the emergency department with pain from acute musculoskeletal injuries.
Patients and methods: Children six to 17 years old with pain from a musculoskeletal injury (to extremities, neck, and back) that occurred in the preceding 48 hours before presentation in the emergency department were randomly assigned to receive orally 15 mg/kg acetaminophen, 10 mg/kg ibuprofen, or 1 mg/kg codeine. Children, parents, and the research assistants were blinded to group assignment. The primary outcome was change in pain from baseline to 60 minutes after treatment with study medication as measured by using a visual analog scale.
I was sorely disappointed that, as the authors state, at best 50% of children achieved adequate analgesia with the highest recommended dose of ibuprofen.
Results: A total of 336 patients were randomly assigned, and 300 were included in the analysis of the primary outcome (100 in the acetaminophen group, 100 in the ibuprofen group, and 100 in the codeine group). Study groups were similar in age, gender, final diagnosis, previous analgesic given, and baseline pain score. Patients in the ibuprofen group had a significantly greater improvement in pain score (mean decrease: 24 mm) than those in the codeine (mean decrease: 11 mm) and acetaminophen (mean decrease: 12 mm) groups at 60 minutes. In addition, at 60 minutes more patients in the ibuprofen group achieved adequate analgesia (as defined by a visual analog scale <30 mm) than the other two groups. There was no significant difference between patients in the codeine and acetaminophen groups in the change in pain score at any time period or in the number of patients achieving adequate analgesia.
Conclusions: For the treatment of acute traumatic musculoskeletal injuries, ibuprofen provides the best analgesia among the three study medications.
Pediatric rheumatologists deal with pain. More often than not, pain is the symptom that brings children to our offices. If we make a diagnosis of an inflammatory arthritis, pain control often appears to be relatively straightforward, as we prescribe NSAIDs, DMARDs, and possibly corticosteroids to diminish inflammation and the resultant pain. However, the majority of children who present with pain complaints do not have juvenile inflammatory arthritis or other arthritis. Rather, they have patello-femoral syndrome, hypermobility, or the dreaded “growing pains”—those mysterious wandering leg pains that have the family up half the night and the child completely recovered by daybreak. Which analgesic agent works best for musculoskeletal pain in children is a question of interest to the pediatric rheumatologist.