Nerve Blocks for Pediatric Shoulder Fractures

Recommended Multimodal Approach

Peripheral nerve blocks are medically necessary and should be strongly considered for pediatric shoulder fractures, as they provide superior pain control with fewer adverse effects compared to systemic opioids alone, while forming part of a multimodal analgesic approach, according to the American Academy of Pediatrics 1
The optimal pain management strategy for pediatric shoulder fractures involves combining regional anesthesia with non-opioid analgesics rather than relying solely on systemic medications, as recommended by the American Society of Anesthesiologists 2, 3

Non-opioid baseline therapy, such as NSAIDs and/or paracetamol, should be administered pre-operatively or intra-operatively and continued postoperatively, as suggested by the American Academy of Pediatrics 4, 5
Regional anesthesia, including upper extremity nerve blocks, should be performed when available, as they are safe and effective in experienced hands, according to the American Society of Regional Anesthesia and Pain Medicine 3, 6
Adjunctive medications, such as IV dexamethasone, can be used to prolong block duration and reduce supplemental analgesic requirements, as recommended by the American Society of Anesthesiologists 4

Continuous interscalene block is preferred over single-shot for extended pain relief in surgical cases, according to the American Society of Regional Anesthesia and Pain Medicine 4
Ultrasound guidance should be used whenever available for safety and efficacy, as recommended by the American Institute of Ultrasound in Medicine 3, 6

At the basic level, intravenous or rectal NSAIDs and/or paracetamol, local wound infiltration with long-acting local anesthetic, and intravenous opioids in divided doses as needed should be used, as suggested by the American Academy of Pediatrics 7
At the intermediate level, ultrasound-guided peripheral nerve block with long-acting local anesthetic plus adjunct, and intravenous opioids only if regional anesthesia is contraindicated or unsuccessful, should be used, according to the American Society of Anesthesiologists 7, 3
At the advanced level, continuous peripheral nerve block with long-acting local anesthetic combined with clonidine, and consideration of intraoperative ketamine or alpha-2 agonists for opioid-sparing effect, should be used, as recommended by the American Society of Anesthesiologists 7, 3, 6

Local anesthetic concentrations should be kept low to minimize risk while maintaining efficacy, according to the American Society of Regional Anesthesia and Pain Medicine 8
Monitoring requirements, including acute pain service availability, regular pain assessments, and clear communication with the surgical team, should be in place, as recommended by the American Society of Anesthesiologists 8, 9

Nerve blocks should be considered early in the treatment pathway in the emergency department setting, according to the American Academy of Pediatrics 9, 1
Multimodal analgesia should be begun pre-operatively, and regular NSAIDs and paracetamol should be continued after block resolution to prevent rebound pain, as recommended by the American Society of Anesthesiologists 4, 5