There is a suggestion non-steroidal anti-inflammatory medications (NSAIDs) e.g. ibuprofen, effect fracture healing. One camp saying they slow fracture healing, whilst a contrasting group say that they are a safe effective pain killer. What is the science behind both camps, and what choices did I make in using ibuprofen?
Fracture healing – Does Ibuprofen help or hinder?
NSAIDS, help or harm?
If you look around the Internet, there are some interesting comments about the use of non-steroidal anti-inflammatory medications (NSAIDs) with fractures. One camp saying they slow fracture healing, and might contribute to fracture non-union rates, where the bone fails to heal, and one saying that they are an effective pain killer, reducing inflammation, helping people deal with the injury and have no effect on the fracture.
I thought it might be interesting to have a look at the science behind the two arguments and see what I did…
For most people, the drugs in question are going to be over the counter Ibuprofen, or possibly prescribed Naproxen or Diclofenac as these are the more commonly used
I feel it’s important to put the medical disclaimer up again here. Posts such as this are intended as interest pieces, not health advice, and should NEVER be used instead of consulting your own General Practitioner or medical team, who are best placed to advise you on your own care.
NSAIDs as a painkiller
So first things first, NSAIDs are a very effective pain killers for many people, but due to their mechanism of action have to be avoided by certain groups of people, most commonly, but certainly not exclusively, those with kidney problems, asthmatics, and people at risk of stomach ulcers.
The discussion over where NSAIDs interfere with bone healing has been going on for many years, with conflicting studies supporting both arguments. As with many sections of this blog, my intention is to show what I did, with regard to my fracture, and the information I used to come to those conclusions.
One source that I used is: Do Nonsteroidal Anti-Inflammatory Drugs Affect Bone Healing? A Critical Analysis
The overall summation of this review is we really don’t know, go cautiously, and if additional risks from other areas, nutrition, age, et.c, then avoid
Another article is BANDOLIER JOURNAL which comes down distinctly more on the side: there is no evidence to support negative effects on bone healing, and use should not be discouraged.
Process of bone healing
To put both papers in some perspective, let’s look at how bone heals, broadly
- bone fractures and blood supply is damaged
- Cytokines released
- Bone stem cells become activated and increase in number
- Soft callus – like a scan forms
- Soft callus changes to hard callus – when the scab has healed, but still clearly been a cut
- Remodelling to normal bone – when the skin returns to normal
- We know that the following factors affect bone healing
- smoking – don’t do it!!
- Size of fracture gap to be filled
- Nutritional status of the patient
- Blood flow to site – which feeds back into DONT SMOKE
- Instability at the fracture – I.e. Be gentle with the fracture when the cast is off!
Bone healing and NSAIDs
NSAIDs, nonsteroidal anti inflammatory drugs, block production of a chemical group called prostaglandins, which are directly involved in the process of inflammation.
One of the issues with the debate is prostaglandins have been shown, in lab experiments, to activate cells that build bone, AND also activate cells that break it down. Now it makes sense you need both when healing a fracture, like demolishing the rotten parts of a building, before you can renovate and build new. Similarly, you need to prepare the ends of a fracture, before your body can build on it.
Those same studies show if you block one type of prostaglandin inducer (COX2) in a mouse, the bones don’t heal very well, but if you block another (COX1) , there doesn’t appear to be an effect. Medications like ibuprofen, are not selective, and block both COX 1&2
The problem is the full science of fracture repair is still being discovered, as we know these chemicals affect bone healing and repair, but we don’t know quite what they do,
It’s a little bit like the new hotel build being delayed. All we know is it’s not ready, but we don’t know if the problem is the plumber, or the plasterer.
What does the literature say?
In the first review 18 studies looking at cells in Petri dishes found all outcomes, NSAIDS slow bone healing, low doses promote healing, high doses stop bone healing, and ibuprofen has no effect.
I put ibuprofen has no effect, as all of the other medications used, were less commonly used NSAIDs,.
At this stage the lab rats suggest ibuprofen might be ok.. Everything else, not sure
Several animal models suggests NSAIDs impair bone healing, but when further studies tried specifically to replicate these outcomes, they could not, even using the same animals, techniques and drugs. So jury still completely out
There are few studies in humans looking at the effect of NSAIDs on fractures. One study found no effect in women with wrist fractures.
One study were completely the other way and found a 3x greater risk of a fracture not to heal if NSAIDs used in first 90 days after fracture
But as many clinical studies found no effect on healing in humans as found ibuprofen fracture healing is impaired.
This suggests there may be something else going on in the studies or patients who did have problems, and certainly that’s something we need to look further at.
What decision did I come to?
So what did I do? NSAIDs are GREAT pain killers, no question. As I have had very well controlled pain, and I could find strong evidence to support a benefit to healing from NSAIDs I’ve decided to avoid them whilst the fracture heals – although I appreciate there are alleged other heal benefits from using NSAIDs, my short term goal is to heal my arm.
If I had been in a lot of pain, and used everything else available, I’d probably have used NSAIDs, but as it stands, I felt I didn’t need to use them.
Again this is not health advice, this is my experience and my thought processes coming to my personal conclusion