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Is opioid analgesia superior to NSAID analgesia in children with musculoskeletal trauma?
  1. Luisa Cortellazzo Wiel1,
  2. Federico Poropat2,
  3. Egidio Barbi1,2,
  4. Giorgio Cozzi2
  1. 1Pediatrics, University of Trieste, Trieste, Italy
  2. 2Pediatrics, Institute for Maternal and Child Health–IRCCS ‘Burlo Garofolo’, Trieste, Italy
  1. Correspondence to Dr Luisa Cortellazzo Wiel, University of Trieste, Trieste 34127, Italy; luisacortellazzowiel{at}

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Clinical bottom line

  • Opioid regimens were not superior to non-opioid regimens in improving pain relief (grade B).

  • A slightly higher incidence of side effects was reported with opioid regimens when compared with non-steroidal anti-inflammatory drugs (grade A).

  • Available evidence does not support the routine use of opioids in children with musculoskeletal injuries attending the emergency department (grade B).


A 9-year-old girl arrives at the paediatric emergency department (ED), after falling while skating.

On arrival, the girl is fine, but she feels severe pain in her left wrist. She reports a pain level 8 on a rating scale of 0–10. The examination does not reveal any bone deformity, but the left wrist is swollen, and the movements of the left hand are limited.

Clinical question

Which would be the ideal analgesic drug to manage pain in this girl?

Is opioid analgesia preferable to non-opioids in children with musculoskeletal injuries in terms of efficacy and safety?


Primary sources: PubMed from January 2000 to June 2019 using (pharmacological treatment OR opioid OR morphine OR fentanyl OR codeine OR tramadol OR NSAID OR ibuprofen OR ketoprofen OR ketorolac OR diclofenac OR indomethacin OR acetaminophen OR paracetamol) AND (emergency) AND (musculoskeletal OR trauma OR injury OR pain) AND (children OR adolescents). We identified 273 unique articles, and reviewed 12 full articles. Five studies were excluded: one investigating the management of pain from different acute conditions, such as abdominal and musculoskeletal pain, without a specific subgroup analysis regarding patients with musculoskeletal injuries,1 another one addressing the pharmacological treatment for postdischarge pain control,2 and three studies comparing opioids with ketamine, as the latter is not routinely used in the paediatric ED setting.3–5 This review included seven studies, all double-blind randomised controlled trials (RCTs), selected in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement6 (table …

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  • Contributors GC conceived and designed the work. LCW, GC and FP analysed the data and drafted the first version of the text. EB reviewed and edited the work. All authors approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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