Ketorolac Administration During Admission Is Not Associated With Nonunion Following Treatment of Pediatric Femoral Shaft Fractures

BACKGROUND: Ketorolac is a common component of multimodal analgesia protocols; however, there are concerns that it may increase the risk of pediatric fracture nonunion, particularly in femoral shaft fractures. The purpose of this study was to determine whether perioperative ketorolac administration is associated with an increased risk of nonunion in operatively treated pediatric femoral shaft fractures. METHODS: We conducted an IRB-approved retrospective review of all pediatric patients (age <18 y) who underwent operative management of femoral shaft fractures at a single institution between May 1, 2012, and December 31, 2024. Patients aged ≥18 years, those treated nonoperatively, with underlying bone pathology, inadequate follow-up, or nondiaphyseal fractures were excluded. The primary outcome was radiographic nonunion, determined by the Radiographic Union Scale for Tibia score and treating surgeon documentation. Secondary outcomes included postoperative opioid consumption, pain scores, and hospital length of stay. RESULTS: Nonunion was rare in this cohort, occurring in 1/122 patients (0.8%) who received ketorolac and 1/21 patients (4.8%) who did not receive ketorolac ( P =0.27). Patients who received ketorolac required fewer opioids, averaging 0.13±0.17 (95% CI 0.10-0.16) versus 0.23±0.28 (95% CI 0.10-0.35) MME/kg in the first 24 hours postoperatively ( P =0.047) and 0.44±0.84 (95% CI 0.29-0.59) versus 3.98±6.57 (95% CI 0.99-6.97) MME/kg cumulatively throughout admission ( P <0.001). Pain scores did not differ significantly between the ketorolac and no-ketorolac groups in the first 24 hours ( P =0.30) or cumulatively ( P =0.50). CONCLUSIONS: This comparative case series demonstrates that nonunion in operatively treated pediatric femoral fractures is rare regardless of ketorolac administration. In addition, ketorolac use appears to be associated with reduced opioid requirements without increasing pain scores. LEVEL OF EVIDENCE: Level III-therapeutic study.