Trauma hurts like hell. Over the years, we’ve developed quite a few ways of combating this pain. A number of drug classes have been developed to reduce it. One of the more common non-narcotic drug classes are the NSAIDs. As I’ve mentioned before, every drug has dozens of effects. Drug companies market a particular medication based on one of the predominant effects. All the others are considered side effects.
NSAIDs are not unique; they have lots of side effects as well. In 2003, several papers brought to light possible interactions between these drugs and fracture healing. Specifically, there were questions about these drugs interfering with the healing process and of increasing the number of delayed unions or nonunions. But once again, how convincing were these papers, really?
It would seem to make sense that NSAIDs could interfere with bone healing. This process relies heavily on the regulation of osteoblast and osteoclast function, which itself is regulated by prostaglandins. Since prostaglandins are synthesized by the COX enzymes, COX inhibitors like the NSAIDs should have the potential to impair this process. Indeed, animal studies in rats and rabbits seem to bear this out.
But as we have seen before, good animal studies don’t always translate well to human experience. Although a study from 2005 suggested that NSAID administration in older patients within 90 days of injury had a higher incidence of fracture nonunion, the study design was not a very good one. It is equally likely that patients who required these drugs in this age group may have been at higher risk for nonunion in the first place.
In fact, there are no large, prospective randomized studies that have explored the effect of short-term or long-term NSAID administration on fracture repair. But there have been several smaller studies that showed absolutely no effect on nonunion with short-term administration of this drug class. Yet the dogma that leads us to avoid giving these drugs persists.
Bottom line: Once again, the animal data is clear but the human data is not. Although there are theoretical concerns about their use, there is not enough solid risk:benefit information to abandon short-term NSAID use in patients who really need them. NSAIDs can and should be prescribed in patients with short-term needs and simple fractures.
- Effects of nonsteroidal anti-inflammatory drugs on bone formation and soft-tissue healing. J AM Acad Orthop Surg 12:139-43, 2004.
- Effect of COX-2 on fracture-healing in the rat femur. J Bone Joint Surg Am 86:116-123, 2004.
- Effects of perioperative anti-inflammatory and immunomodulating therapy on surgical wound healing. Pharmacotherapy 25:1566-1591, 2005.
- Pharmacological agents and impairment of fracture healing: what is the evidence? Injury 39:384-394, 2008.
- High dose nonsteroidal anti-inflammatory drugs compromise spinal fusion. Can J Anaesth 52:506-512, 2005.
Okay, time for the answer. This 12 year old crashed his moped, taking handlebar to the mid-epigastrium. Over the next 3 days, he felt progressively worse and finally couldn’t keep food down.
Mom brought him to the ED. The child appeared ill, and had a WBC count of 18,000. The abdomen was firm, with involuntary guarding throughout and a hint of peritonitis. The diagnosis was made on the single abdominal xray shown yesterday. A closeup of the good stuff is above.
Emergency docs, your differential diagnosis list with this history is a pancreatic vs a duodenal injury based on the mechanism.
Classic findings for duodenal injury:
- Scoliosis with the concavity to the right. This is caused by psoas muscle irritation and spasm from retroperitoneal soiling by the duodenal leak.
- Loss of the psoas shadow on the right. Hard to see on this xray, but the left psoas shadow is visible, the right is not. This is due to fluid and inflammation along this plane.
- Air in the retroperitoneum. In this closeup, you can actually see tiny bubbles of leaked air outlining the right kidney. There are also bubbles along the duodenum and a few along the right psoas.
We fluid resuscitated first (important! dehydration is common and can lead to hemodynamic issues upon induction of anesthesia) and performed a laparotomy. There was a blowout in the classic position, at the junction of 1st and 2nd portions of the duodenum. The hole was repaired in layers and a pyloric exclusion was performed, with 2 closed drains placed in the area of the leak.
The child did well, and went home after 5 days with the drains out. Feel free to comment or leave questions!
I’ll be travelling through France for the next two weeks, stopping by a few hospitals to visit, I hope. France is in my top 10 list of international readers. And interestingly, most of my French readers are not in Paris!
Most of my posts will be “Best Of” while I am away. Additionally, there will not be a Trauma MedEd newsletter this month. But I’ll make it up to you in June!
Follow my progress on FourSquare and Twitter! I hope to meet some of my international readers out there! Tweet me if I’m in your neighborhood.
Here’s a case related to yesterday’s post on preventing handlebar injuries. Have a look at this image:
This alone is enough for you to make the diagnosis. More info, and answers tomorrow.
“Necessity is the mother of invention”
I’ve managed several cases of injury due to bicycle handlebars over the years. Typically, a smaller child crashes his or her bike, and the handlebar hits them in the epigastrium. Children have thinner abdominal walls and less developed muscular to protect them, so this very focal impact can do a lot of damage.
There is now a clever and inexpensive solution available that can decrease the number of injuries we see from this common mechanism. It’s called the Handlebar Helmet, and was developed by the parents of a 4 year old boy who suffered this injury. It is essentially a special plastic cap that fits on the end of the handlebars. It’s designed to diffuse the pressure of any impact with the handlebar. This product actually does double duty, protecting during a crash, and also preventing injury if a child trips and falls on a bike that is lying down.
The product is very easy to install, and comes in multiple colors so it can be “cool” (very important to kids). This is a nice, simple idea that can prevent potentially devastating injuries.
Over the next two days, I’m going to rerun an interesting pediatric case of handlebar injury.
Reference: The Handlebar Helmet. www.handlebarhelmet.com
Note: I have no financial interest in this product.