Pain After Lower Extremity Fracture Surgery: What Is Normal and How Is It Impacted by Individual-specific and Caregiver-specific Psychosocial Factors?

BACKGROUND: This pilot study characterized normative pain and analgesic consumption following lower-extremity fracture surgery in children. Additionally, we sought to determine how various caregiver- and patient-specific psychosocial factors affect pain, opioid use, and health-related quality-of-life (HRQOL). We hypothesized that the majority of children following lower extremity fracture surgery would not need prolonged opioids, and that higher preoperative anxiety levels would translate into higher postoperative pain and analgesic needs.

METHODS: This was a prospective cohort study of children aged 5-17 years old undergoing operative fixation of an isolated lower extremity fracture at a single pediatric trauma center. Baseline surveys were administered preoperatively assessing anxiety, pain catastrophizing, and pain self-efficacy. Daily pain scores and analgesic consumption were collected on postoperative days (POD) 1-7, 10, 14, and 21. HRQOL was assessed via PROMIS Global Health, and functional recovery was assessed via PROMIS Mobility. Clinical data were abstracted from the medical record. Descriptive and bivariate statistics were performed.

RESULTS: A total of 63 patients with a mean age of 13.0 ± 2.6 years were included. The most common fracture locations were the ankle (49%), tibia (27%), and femur (17%). Mean daily pain scores peaked at 4.5/10 on POD1 and steadily decreased thereafter. By POD3, 62% of patients had mild pain or less (score ≤3/10), and 53% were no longer taking any opioids. The majority of caregivers (55%) and patients (61%) reported pain-related anxiety of ≥6/10 prior to surgery; 76% of caregivers and 50% of patients were at least moderately confident in their ability to adequately manage pain. Neither caregiver nor patient pain-related anxiety or self-efficacy was significantly related to postoperative pain scores, satisfaction with pain management, or opioid consumption. Caregiver pain catastrophizing and generalized anxiety also did not affect patient outcomes. One week after surgery, anxious children had lower average pain scores (1.2 vs 2.7; P = .005) and were less likely to still be using nonopioid analgesics (47% vs 88%, P = .013).

CONCLUSIONS: This pilot study contributes preliminary data for postoperative pain, analgesic consumption, and functional recovery following operative treatment of lower extremity fractures that can be used to guide prescribing practices and preoperative expectation management/family education. More work is needed to validate and build upon these findings before they can be safely extrapolated to other clinical scenarios and age groups.

KEY CONCEPTS: (1)In this cohort of children following lower extremity fracture surgery of all types, mean daily pain scores peaked at 4.5 on postoperative day one and steadily decreased thereafter.(2)By POD3, most patients had mild pain or less and the majority were no longer taking any opioid analgesics.(3)The majority of children continue to take nonopioid analgesics (acetaminophen and/or ibuprofen) for a week (or longer) after lower extremity fracture surgery.(4)In this cohort, high-anxiety children tended to report lower pain and take fewer opioids after lower extremity fracture surgery.(5)Although baseline pain-related anxiety was not significantly associated with postoperative outcomes, it remained a significant concern for many families and children, suggesting further work is necessary to determine if, and to what extent, targeted interventions might be helpful.

LEVEL OF EVIDENCE: II, prospective cohort study.