Clin Orthop Surg.  2018 Dec;10(4):455-461. 10.4055/cios.2018.10.4.455.

Effect of Surgical-Site, Multimodal Drug Injection on Pain and Stress Biomarkers in Patients Undergoing Plate Fixation for Clavicular Fractures

• Yoo JS
• Heo K
• Kwon SM
• Lee DH
• Seo JB

• KMID: 2426531
• DOI: http://doi.org/10.4055/cios.2018.10.4.455

Abstract

BACKGROUND
Surgical-site, multimodal drug injection has recently evolved to be a safe and useful method for multimodal pain management even in patients with musculoskeletal trauma.
METHODS
Fifty consecutive patients who underwent plating for mid-shaft and distal clavicular fractures were included in the study. To evaluate whether surgical-site injections (SIs) have pain management benefits, the patients were divided into two groups (SI and no-SI groups). The injection was administered between the deep and superficial tissues prior to wound closure. The mixture of anesthetics consisted of epinephrine hydrochloride (HCL), morphine sulfate, ropivacaine HCL, and normal saline. The visual analogue scale (VAS) pain scores were measured at 6-hour intervals until postoperative hour (POH) 72; stress biomarkers (dehydroepiandrosterone sulfate [DHEA-S], insulin, and fibrinogen) were measured preoperatively and at POH 24, 48, and 72. In patients who wanted further pain control or had a VAS pain score of 7 points until POH 72, 75 mg of intravenous tramadol was administered, and the intravenous tramadol requirements were also recorded. Other medications were not used for pain management.
RESULTS
The SI group showed significantly lower VAS pain scores until POH 24, except for POH 18. Tramadol requirement was significantly lower in the SI group until POH 24, except for POH 12 and 18. The mean DHEA-S level significantly decreased in the no-SI group (74.2 ± 47.0 µg/dL) at POH 72 compared to that in the SI group (110.1 ± 87.1 µg/dL; p = 0.046). There was no significant difference in the insulin and fibrinogen levels between the groups. The correlation values between all the biomarkers and VAS pain scores were not significantly different between the two groups (p > 0.05).
CONCLUSIONS
After internal fixation of the clavicular fracture, the surgical-site, multimodal drug injection effectively relieved pain on the day of the surgery without any complications. Therefore, we believe that SI is a safe and effective method for pain management after internal fixation of a clavicular fracture.

Keyword

Clavicle; Fracture; Postoperative pain

MeSH Terms

Anesthetics
Biomarkers*
Clavicle
Epinephrine
Fibrinogen
Humans
Insulin
Methods
Morphine
Pain Management
Pain, Postoperative
Tramadol
Wounds and Injuries
Anesthetics
Biomarkers
Epinephrine
Fibrinogen
Insulin
Morphine
Tramadol

Figure

• 

  Fig. 1 Comparison of visual analogue scale score for pain between the two groups. Statistically significant differences are indicated by asterisks. SI: surgical-site injection, Preop: preoperative, PACU: postanesthesia care unit.

• 

  Fig. 2 Comparison of additional rescue-tramadol requirement between the two groups. Statistically significant differences are indicated by asterisks. SI: surgical-site injection.

• 

  Fig. 3 (A) At postoperative hour (POH) 72, the mean dehydroepiandrosterone sulfate (DHEA-S) level significantly decreased in the no-surgical-site injection (SI) group (74.2 ± 47.0 µg/dL) as compared to that in the SI group (110.1 ± 87.1 µg/dL; p = 0.046). (B, C) There were no significant changes in the levels of insulin and fibrinogen until POH 72 (p > 0.05). All the values are presented as the mean and the standard deviations. Preop: preoperative.

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