title: Pain management of musculoskeletal injuries in children: current state and future directions.
abstract: BACKGROUND
  Pain is the most common reason for seeking health care in the Western world and is a contributing factor in up to 80% of all emergency department (ED) visits. In the pediatric emergency setting, musculoskeletal injuries are one of the most common painful presentations. Inadequate pain management during medical care, especially among very young children, can have numerous detrimental effects. No standard of care exists for the management of acute musculoskeletal injury-related pain in children. Within the ED setting, pain from such injuries has been repeatedly shown to be undertreated.
  
  
  OBJECTIVE
  Upon completion of this CME article, the reader should be better able to (1) distinguish multiple nonpharmacological techniques for minimizing and treating pain and anxiety in children with musculoskeletal injuries, (2) apply recent medical literature in deciding pharmacological strategies for the treatment of children with musculoskeletal injuries, and (3) interpret the basic principles of pharmacogenomics and how they relate to analgesic efficacy.
  
  
  RESULTS
  Pediatric musculoskeletal injuries are both common and painful. There is growing evidence that, in addition to pharmacological therapy, nonpharmacological methods can be introduced to improve analgesia in the ED and after discharge. Traditionally, acetaminophen with codeine has been used to treat moderate orthopedic injury-related pain in children. Other oral opioids (hydrocodone, oxycodone) are gaining popularity, as well. Current data suggest that ibuprofen is at least as effective as acetaminophen-codeine and codeine alone. Medication compliance might be improved if adverse effects were minimized, and ibuprofen has been shown to have a similar or better adverse effect profile than the oral opioids to which it has been compared. Pharmacogenomic data show that nearly 50% of individuals have at least 1 reduced functioning allele resulting in suboptimal conversion of codeine to active analgesic, so it is not surprising that codeine analgesic efficacy is not optimal. At the same time, nonpharmacological therapies are emerging as commonly used treatment options by parents and adjuncts to analgesic medication. The efficacy and role of techniques (massage, music therapy, transcutaneous electrical nerve stimulation), although promising, require further clarification in the treatment of orthopedic injury pain.
  
  
  CONCLUSIONS
  There is a need to optimize the measurement, documentation, and treatment of pain in children. There is growing evidence that nonpharmacological methods can be introduced to improve analgesia in the ED, and efforts to help parents implement these methods at home might be advantageous to optimize outpatient treatment plans. In pharmacotherapy, ibuprofen has emerged as an appropriate first-line choice for mild-moderate orthopedic pain. Other oral opioids (hydrocodone, oxycodone) are gaining popularity over codeine, because of the current understanding of the pharmacogenomics of such medications.
authors.affiliation: Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada. sali@)ualberta.ca
authors.forename: Samina
authors.initials: S
authors.lastname: Ali
authors.forename: Amy L
authors.initials: AL
authors.lastname: Drendel
authors.forename: Janeva
authors.initials: J
authors.lastname: Kircher
authors.forename: Suzanne
authors.initials: S
authors.lastname: Beno
mesh_terms: D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D002648:Child; D003061:Codeine / Q000235:genetics; D019389:Cytochrome P-450 CYP2D6 / Q000235:genetics; D005838:Genotype; D006801:Humans; D007052:Ibuprofen / Q000008:administration & dosage; D009141:Musculoskeletal System / Q000293:injuries*; D010146:Pain / Q000188:drug therapy; D059408:Pain Management; D010147:Pain Measurement; D010597:Pharmacogenetics
chemical_list: D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D019389:Cytochrome P-450 CYP2D6; D003061:Codeine; D007052:Ibuprofen