Opioid-free Postoperative Pain Management in Pediatric Upper Limb Fracture Surgery: A Prospective Observational Study

BACKGROUND: Postoperative pain management in pediatric fracture surgery is challenging. Opioid analgesics, conventionally used for moderate-to-severe pain, are associated with significant adverse effects in children, including respiratory depression, nausea, and sedation. Growing emphasis on opioid stewardship has increased interest in opioid-free strategies; however, real-world data in pediatric orthopedic trauma remain limited. OBJECTIVES: The objective is to evaluate postoperative pain outcomes and analgesic requirements in children undergoing upper limb fracture surgery managed with a standardized opioid-free protocol. METHODS: This prospective observational study included children aged 5-18 years who underwent closed reduction and internal fixation of upper limb fractures between January and December 2025. All patients received scheduled postoperative acetaminophen. Ibuprofen was permitted only as rescue analgesia for persistent moderate pain. Pain intensity was assessed using the Numerical Rating Scale (NRS) on postoperative days (POD) 1, 2, and 3. Analgesic requirements, hospital stay, and adverse events were recorded. RESULTS: Fifty patients were included (30 males, 20 females; mean age 11.2 ± 2.8 years). Mean NRS scores decreased significantly from POD 1 (4.02 ± 0.96) to POD 2 (2.78 ± 0.88) and POD 3 (1.64 ± 0.82) (P < 0.001). Rescue ibuprofen was required in six patients (12%). No patient required opioids, and no analgesic-related adverse events were observed. CONCLUSION: An acetaminophen-centered, opioid-free protocol provided effective pain control following pediatric upper limb fracture surgery and markedly reduced the need for additional analgesia. These findings support the feasibility and safety of opioid-free management in pediatric orthopedic trauma.