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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: January 21, 2015
Expiration Date: January 21, 2016

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Program ID: 1405237K2

Last week 564 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 202 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

In Children with Uncomplicated Extremity Fractures, Oral Ibuprofen is as Effective as Oral Morphine for Pain Reduction and has Fewer Adverse Events

Reference: CMAJ 2014 Dec 9;186(18):1358 (level 1 [likely reliable] evidence)

Extremity fractures are common and often painful injuries in children presenting to the emergency department. Most children report the highest level of pain at the time of the injury or within 48 hours of injury (Pediatr Emerg Care 2006 Feb;22(2):94) and inadequate pain management may increase healing time (Pediatr Emerg Care 2010 Jul;26(7):518). Concerns about prescribing opioids have left physicians looking for other options for pain management. A recent randomized trial compared oral ibuprofen vs. morphine every 6 hours as needed for 24 hours after discharge in 183 children presenting to the emergency department with uncomplicated extremity fractures. All children were also allowed to take acetaminophen for breakthrough pain.

Children in the trial had fractures of the radius, ulna, clavicle, humerus, elbow, forearm, tibia, or fibula. Children not experiencing pain severe enough to use an analgesic were excluded from the analysis and this represented 26.8% of the children with fractures. Pain was assessed immediately before and 30 minutes after each analgesic dose using the Revised Faces Pain Scale with a range of 0-5 (a higher score indicates more severe pain). The median pain score at discharge was 2. All analgesic doses achieved a pain reduction greater than the minimal clinically important difference of 1 point. There was no significant difference in pain reduction comparing morphine vs. ibuprofen, and no significant difference between groups in the percentage of patients requiring acetaminophen for breakthrough pain. Morphine was also associated with an increase in adverse events compared to ibuprofen (56.1% vs. 30.9%, p < 0.01 NNH 4). Most commonly reported adverse events included nausea, vomiting, and drowsiness.

The results of this trial indicate that over-the-counter ibuprofen is as effective for pain relief as morphine and has fewer adverse events. There are some limitations to the design of the study which are worth noting. The timing of pain assessment is fine for ibuprofen, but narcotics such as morphine often lose their effectiveness after 4 hours and so checking a before dose pain level at 6 hours may not represent the optimal degree of effectiveness. Nonetheless, given the increased rate of adverse effects as well as the more widespread problem of prescription opioid abuse (often diverted from pills prescribed for appropriate indications and not used), knowing that ibuprofen will give comparable pain relief can be reassuring to prescribers who do not want patients to have untreated pain. One additional consideration about this trial relates to the issue of NSAID safety. NSAIDs inhibit bone healing in animal models and have been associated with nonunion and malunion in some studies of fractures in adults (typically fractures requiring surgical repair) (J Trauma Acute Care Surg. 2014 Mar;76(3):779, Acta Orthop. 2012 Dec;83(6):653, Curr Opin Rheumatol. 2013 Jul;25(4):524). However, studies of non-complicated bone fractures in children demonstrate no significant relationship between NSAIDs and bone healing or functional outcomes (J Pediatr Orthop. 2010 Oct-Nov;30(7):655, Ann Emerg Med. 2009 Oct;54(4):553, Can Fam Physician. 2014 Sep;60(9):817). In summary, for children with uncomplicated extremity fracture, ibuprofen may provide safe and effective pain relief thereby limiting the use of opioids.

For more information, see the Tibial plateau fracture, Clavicular fracture, Buckle fracture of distal radius, and Distal radius fracture topics in DynaMed.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Oncology (especially Breast cancer, Head and neck cancer, Pancreatic cancer), Ophthalmology, Orthopedics, Pediatric Neurology, and Vascular.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

PEMSoft Mobile

Free Trial of PEMSoft Mobile Available For iPhone, iPad, and Android Devices

The PEMSoft Mobile app, a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools, is now available from EBSCO Health. Designed by pediatricians, emergency physicians and other medical specialists, the vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

Content in the PEMSoft Mobile app covers more than 3,000 conditions and includes a similar number of medical illustrations, clinical images and videos. PEMSoft Mobile also includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms, and topics covering pediatric injuries and management approaches.

Visit the PEMSoft Mobile App Trial page to access a free trial for both Apple and Android devices.

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