The Management of Pain in Orthopaedics

The three general methods of treating pain are pharmacologic, physical, and psychological. The goal of medical management of the patient with pain and inflammation is to relieve these symptoms with minimal side effects and inconvenience. Pain associated with inflammation may be relieved with nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin. All NSAIDs relieve pain and stiffness in a similar manner; their primary action appears to be the inhibition of the cyclo-oxygenase system in the arachidonic acid cascade. When prescribing NSAIDs for orthopaedic pain and inflammation, it seems sensible to start with aspirin because of its low cost and safety at analgesic doses. However, if safety and low incidence of side effects are the most important factors in determining appropriate therapy, newer NSAIDs such as ketoprofen will be preferred. The relief of pain is an important aspect of postoperative care. Parenteral and oral opiates serve as the standard against which other therapies for severe pain are compared. When pain cannot be adequately controlled with intramuscular or subcutaneous opiates, intravenous opiates controlled by the patient (patient-controlled analgesia) are often useful. Relatively small doses of epidural or intrathecal opiates can also be used to achieve postoperative pain relief. Thus, treatment for orthopaedic pain begins with NSAIDs, followed by an oral opiate combined with acetaminophen, aspirin, or another NSAID. If these regimens are ineffective, oral opiates followed by parenteral opiates may be tried.