Pain Management of Pediatric Musculoskeletal Injury in the Emergency Department: A Systematic Review

Table 1

Characteristics of included studies.

Author	Participants	Intervention	Main outcome	Findings
Borland et al. 2007 [44]	children with acute long-bone fractures; Age: 7 to 15 years	Group 1: , IN fentanyl 1.4 μg/kg; Group 2: , IV morphine 0.1 mg/kg	Difference in MPS greater than 13 mm on the VAS at 5 minutes after analgesic administration	No significant differences in pain scores between groups at all study points
Clark et al. 2007 [45]	children with acute musculoskeletal pain; Age: 6 to 17 years	Group 1: , acetaminophen 15 mg/kg; Group 2: , ibuprofen 10 mg/kg; Group 3: , codeine 1 mg/kg	Difference in MPS greater than 15 mm on the VAS at 60 minutes after analgesic administration	(i) Ibuprofen group showed significantly greater reduction in VAS but only 52% of participants in this group received adequate analgesia (VAS < 30 mm)
Friday et al. 2009 [46]	children with fractures or dislocations; Age: 5 to 17 years	Group 1: , ibuprofen 10 mg/kg, (max 400 mg); Group 2: , acetaminophen + codeine 15 mg/kg and 1 mg/kg (max 60 mg codeine)	Difference in MPS greater than 2 cm on the CAS at 40 minutes after analgesic administration	Equivalent analgesic effectiveness of both agents at 40 minutes
Furyk et al. 2009 [47]	children with suspected limb fractures; Age: 4 to 13 years	Group 1: , nebulized fentanyl 4 μg/kg; Group 2: , IV morphine 0.1 mg/kg	Difference in mean pain score greater than 1 face on the WBS at 15 and 30 minutes after analgesic administration	(i) Significantly decreased pain scores in both groups at all study time points; (ii) No significant differences in pain scores between groups
Graudins et al. 2015 [48]	children with limb injury; weighing < 50 kg; Age: 3 to 13 years	Group 1: , IN ketamine 1 mg/kg + ibuprofen 10 mg/kg; Group 2: , IN fentanyl 1.5 μg/kg + ibuprofen 10 mg/kg	Median reduction in pain 30 min after analgesic administration; FPS-R for children aged 3 to 6 and VAS for children 7 years and older	Similar pain reduction in both groups
Kendall et al. 2001 [49]	children with a clinical fracture of an upper or lower limb in the ED; Age: 3 to 16 years	Group 1: , IN diamorphine spray 0.1 mg/kg; Group 2: , IM morphine 0.2 mg/kg	Pain score on WBS at 30 minutes after analgesic administration	(i) Both medications significantly reduced pain; (ii) Onset of pain relief was faster in the IN spray group than IM (lower pain scores at 5, 10, and 20 minutes); (iii) No difference between groups at 30 minutes
Le May et al. 2013 [50]	children with limb trauma; Age: 6 to 18 years	Group 1: , ibuprofen 10 mg/kg + codeine 1 mg/kg (max 60 mg); Group 2: , ibuprofen 10 mg/kg (max 600 mg) + placebo	Difference in MPS of 20 mm on the VAS at 90 minutes after analgesic administration	No significant differences in mean pain scores between groups at all study time points
Neri et al. 2013 [51]	children with suspected fracture or dislocation; Age: 4 to 17 years	Group 1: , ketorolac (SL) 0.5 mg/kg; Group 2: , tramadol (SL) 2 mg/kg	McGrath scale for children up to 6 years and VAS for those older than 6 years. Primary outcome was MPS < 5/10 on a 0–10 VAS at 120 minutes.	(i) Significant reduction in mean pain scores in both groups; (ii) No significant differences in pain scores between groups at 120 minutes; (iii) Rescue dose of paracetamol-codeine administered in 2/60 children in the ketorolac group versus 8/65 in the tramadol group (not significant)

Note: medications were given orally, except where otherwise indicated.
CAS: Color Analog Scale; IM: intramuscular; IN: intranasal; IV: intravenous; MPS: Mean Pain Score; RCT: Randomized Controlled Trial; SL: sublingual; VAS: Visual Analog Scale; WBS: Wong-Baker faces pain scale.