Acute Orthopedic (eg, Bone Fracture, Disc Herniation, Arthritis) and Differential Diagnosis Related Pain
Chikezie N. Okeagu
Meredith K. Shaw
Devin S. Reed
Justin Y. Yan
Introduction
Acute orthopedic pain, or pain of the musculoskeletal system, is perhaps the most common of any of the manifestations of acute pain. The musculoskeletal system is large, consisting of all muscles, bones, joints, and associated tissues such as tendons and ligaments, presenting ample locations from which pain can emanate. Unlike other pain conditions that preferentially affect people of certain ages or genders, musculoskeletal pain does not have a predilection for any specific demographic. It is likely that every person on earth has experienced some form of acute pain involving their musculoskeletal system. As such, proper prevention, identification, and treatment are exceedingly important.
Acute orthopedic pain typically arises from one of two mechanisms: injury or surgery. Musculoskeletal injuries are common, with nearly a third of emergency department visits resulting from injury or trauma.1 This encompasses a variety of etiologies including bone fractures, disc herniation, and sprains, strains, or tears of muscles, ligaments, and tendons. Of these, the most common injuries are those of the back and spine. Next most frequent are sprains, dislocations, and fractures that, when combined with the aforementioned back and spine injuries, account for almost 50% of all musculoskeletal injuries.2 Acute pain after orthopedic surgery is also a significant consideration as orthopedic procedures are regarded as some of the most intensely painful surgeries. This is because the periosteum has the lowest pain threshold of the deep somatic structures, and as a result, bone injury inflicted during surgery is more painful than injury to other tissues. As the number of orthopedic procedures performed every year continues to climb, their contribution to the total burden of acute musculoskeletal pain will become increasingly substantial. Kurtz et al. projected that between 2005 and 2030, total knee arthroplasties, one of the most commonly performed orthopedic procedures, will increase by 673% to nearly 3.5 million yearly. This trend is also predicted to be seen in total hip arthroplasties with an expected increase of 174% over this time frame.3
In addition to the increasing number of orthopedic procedures, the recent shift toward more ambulatory surgeries and earlier discharge after surgery has transformed the appearance of postoperative pain management. Once largely an inpatient endeavor relegated to house officers and floor nurses, decreased lengths of stay have forced surgeons and anesthesiologists to devise new strategies to deliver pain relief while allowing patients to leave the hospital. Coupled with this increase in outpatient procedures has been a realization that poor postsurgical pain management predisposes patients to the development of postoperative complications
such as venous thromboembolism, myocardial ischemia, pulmonary complications, and poor wound healing.4,5 Furthermore, poorly managed acute pain often allows for the progression to chronic pain.2,4 This chapter will present a comprehensive overview of approaches to assessment and management of patients with acute orthopedic pain related to injury or surgery.
such as venous thromboembolism, myocardial ischemia, pulmonary complications, and poor wound healing.4,5 Furthermore, poorly managed acute pain often allows for the progression to chronic pain.2,4 This chapter will present a comprehensive overview of approaches to assessment and management of patients with acute orthopedic pain related to injury or surgery.
Assessment and Patient Education
A thorough history and physical is indispensable in the evaluation of acute musculoskeletal pain complaints. Pain perception is complex, involving not only nociception but also social, emotional, and psychological elements. As a result, pain is a highly subjective experience making it very challenging to accurately assay a patient’s level of discomfort. In fact, across several studies, no association has been found between the severity of musculoskeletal injuries such as ankle sprains and fractures and the intensity of pain reported by patients.6 Because of this, many tools have been developed to aide in the assessment of patients’ pain. While the formats of these tools differ, they all have the same aim; namely, to help quantify pain in order to inform proper treatment.
History and Physical
It is important to collect information regarding onset, position, quality, radiation, severity, aggravating/alleviating factors, and associated symptoms or activities. This will help differentiate orthopedic pain that is related to injury from acute pain resulting from other etiologies such as gout or septic arthritis. The etiology of pain will dictate treatment. While most causes of acute musculoskeletal pain are managed similarly, there are some outliers. Septic arthritis, for example, is a surgical emergency and therefore must be identified quickly. Likewise, while patients with gout may experience some benefit from the analgesic approaches taken with other causes of musculoskeletal pain, it is also important for them to prevent further episodes with lifestyle modifications and prophylactic medications.
Single Rating Pain Scales
Single rating pain scales are widely used. Included in this category are such scales as the Numerical Rating Scale (NRS), the Verbal Rating Scale (VRS), the Visual Analog Scale (VAS), and face rating scales (Fig. 16.1). An essential component of these pain scales is the inclusion of anchor points such as “no pain” and “worst pain imaginable” at either end.4 This allows the patient to weigh their current symptoms in relation to these reference points.
Due to its convenience, the NRS is one of the most commonly used scales in medicine. Application of the scale involves asking patients to rank their pain on a numerical scale, usually 0-10 with 0 corresponding to no pain and 10 to the worst pain imaginable. The validity of this scale has been demonstrated in studies, and its simplicity allows it to be administered quickly. Furthermore, since only numerical values are used, the scale can be applied widely without the need for translation. Despite the many positive aspects of the scale, it does have some shortcomings. The scale only evaluates pain intensity and does not provide a way to assess the several other dimensions of pain (eg, emotional, psychological). Intervals between numbers are not necessarily equal; that is, the difference between a 1 and 2 on the scale is likely not the same as the difference between a 9 and a 10. Additionally, patients are typically asked to rate their current pain or worst level of pain in the preceding 24 hours. Use of the scale in this way fails to properly account for fluctuations in pain symptoms.4,7
The VRS differs from the NRS in that descriptive adjectives such as “mild,” “moderate,” or “severe” are used in lieu of number for pain rating. Just as in the NRS, end points such as “no pain at all” and “extreme pain” are used as references. Like the NRS, the VRS has been demonstrated to be a reliable assessment tool. Since words instead of numbers are used, it may
take more time to administer since patients must read all possible responses before choosing one. Similarly, this may present obstacles when treating patients who are not familiar with the language in which the scale is written. As the response choices are limited, patients may find it difficult to select which adjective best fits their pain. Lastly, just as with the NRS, the difference between mild and moderate pain, for example, is not necessarily the same as the difference between moderate and severe.4,7
take more time to administer since patients must read all possible responses before choosing one. Similarly, this may present obstacles when treating patients who are not familiar with the language in which the scale is written. As the response choices are limited, patients may find it difficult to select which adjective best fits their pain. Lastly, just as with the NRS, the difference between mild and moderate pain, for example, is not necessarily the same as the difference between moderate and severe.4,7
 FIGURE 16.1 Pain assessment tools. |
The VAS is one of the most widely used instruments for pain assessment. It consists of a straight line with the end points denoting the extremes of pain (ie, 0 or “no pain” and 10 or “worst pain imaginable”). Patients are asked to mark the line at a point that corresponds to their pain level. The distance between the left side of the scale and the mark indicates the patient’s level of pain. Variations of the VAS include the mechanical VAS in which patients use a slider on a linear scale rather than drawing a mark and computer-based models of the VAS. Descriptive terms or numerical scales are sometimes added to the VAS. In these instances, the scale is known as a Graphic Rating Scale. Like other single rating scales, VAS and Graphic Rating Scale have been found to be valid tools for assessing pain. Additionally, differences in pain intensity measured with the VAS are representative of the difference in magnitude of pain experienced by the patient. Among the single rating scales, this is unique to the VAS and presents its major advantage of other tools. The VAS is more difficult for some patients to understand making it more susceptible to errors when completing.4,7
Lastly, pain face rating scales have been found to correlate positively with other assessments of pain intensity. Patents are asked to choose from a selection of facial expressions, which represent a level of pain. Similar to the NRS, this scale is advantageous as there is no need for patients to be literate to complete the assessment.4
Pain Assessment Questionnaires
The use of questionnaires allows for a more thorough evaluation of the various dimensions of pain. The McGill Pain Questionnaire is the most commonly used assessments in this category. The first part of the questionnaire consists of an outline of a human on which patients mark
the location of their pain. The second part allows patients to report the intensity of their current pain on a 1-5 scale. The third part consists of 78 words across 20 sections that are related to pain. Different sections are associated with different components of pain, namely affective, sensory, evaluative, and miscellaneous. Each word is assigned a point value, and patients mark as many words as necessary to best describe their pain. A pain rating index is derived by tallying the total number of points. Administration of the McGill Pain Questionnaire can be time consuming and cumbersome. As such, a short-form McGill Pain Questionnaire that can be completed much more quickly is more commonly used.4,7,8
the location of their pain. The second part allows patients to report the intensity of their current pain on a 1-5 scale. The third part consists of 78 words across 20 sections that are related to pain. Different sections are associated with different components of pain, namely affective, sensory, evaluative, and miscellaneous. Each word is assigned a point value, and patients mark as many words as necessary to best describe their pain. A pain rating index is derived by tallying the total number of points. Administration of the McGill Pain Questionnaire can be time consuming and cumbersome. As such, a short-form McGill Pain Questionnaire that can be completed much more quickly is more commonly used.4,7,8
Postoperative Pain Assessment
In the postoperative period, serial assessments should be conducted as a single measurement presents only a “snapshot” and may not appropriately represent a patient’s level of pain. A sensible time interval should be chosen based on the individual situation. Any of the aforementioned tools can be utilized in order to evaluate a patients’ pain symptoms. Subsequent measurements should be compared to monitor progression of pain and efficacy of pain interventions.4
Managing Patient Expectations
Regardless of the method used to assess pain, it is vital to provide patients with proper education regarding their condition and what they can expect from treatment. Patients and health care providers often have differing understandings of what qualifies as successful treatment. A study conducted by Ghomrawi et al. revealed that more than 50% of total joint arthroplasty patients had higher expectations than their surgeons in regard to postoperative pain relief, function, and well-being.9 When treating acute pain, it is important to make patients aware that it may not be safe or even possible to completely eliminate their pain. Schutte et al. conducted a study in which they surveyed patients scheduled to undergo surgery regarding the level of postoperative pain that would be considered satisfactory. Initially, 41% indicated that “no pain” would be the appropriate level of postoperative pain. After educating patients as to what amount of pain control could realistically be achieved postoperatively, >80% were willing to accept a higher level of pain.10 Lastly, it is important to maintain a dialogue with the patient throughout the postoperative period or course of treatment of acute musculoskeletal pain. Recovery can take weeks to months, during which time the patient may experience fluctuating pain symptoms. Physicians should continue to provide education including the most updated information regarding expected outcomes of treatment.
Treatments
The treatment of acute pain from orthopedic injuries is best accomplished by using a multimodal analgesia regimen. 7.7% of opiate prescriptions are from orthopedic surgeons despite the fact that they only represent 2.5% of all physicians.1 A better understanding of pain management of orthopedic injuries can help the patient population combat the opioid epidemic. These include but are not limited to oral analgesics, peripheral blocks, neuraxial blocks, and local infiltrations. Additional therapy such as psychosocial support has also been shown to improve outcomes.1 The combination of opioid analgesia with other treatment modalities such as nonsteroidal anti-inflammatory drugs (NSAIDs) has resulted in better pain outcomes than opioid monotherapy.1,2 Opioids prescribed specifically by a single provider and at the lowest effective dose for the shortest effective time is important in order to decrease opiate use.
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