SCIENTIFIC ARTICLE

Evaluation of Early Postoperative Pain and the

Effectiveness of Perifracture Site Injections Following
Volar Plating for Distal Radius Fractures
Moon Sang Chung, MD, PhD, Young Hak Roh, MD, Goo Hyun Baek, MD, PhD, Young Ho Lee, MD, PhD,
Seung Hwan Rhee, MD, Hyun Sik Gong, MD, PhD

Purpose Few studies have investigated the effectiveness of early postoperative pain control
regimens after volar plating for distal radius fractures. This study evaluated postoperative
levels of pain after volar plating of distal radius fractures under axillary nerve block in
patients with and without injections of local anesthetics, narcotics, and epinephrine around
the fracture site.
Methods Perioperative pain levels were prospectively assessed in 44 consecutive patients
who had had volar plating for a distal radius fracture under axillary nerve block at a mean
time of 2.8 days after trauma. Intravenous, patient-controlled analgesia and prescheduled
analgesic medications were administered to all patients. In addition, patients were randomly
allocated to 2 groups: perifracture site injection (PI; n 22) and no perifracture site injection
(no-PI; n 22). At the end of surgery, PI group patients were administered perifracture site
injections and blocks of the superficial radial and interosseous nerves with a local anesthetic
mixture consisting of ropivacaine, morphine, and epinephrine. During the first 48 hours after
surgery, pain visual analog scale (VAS) scores (0 to 100), total amount of narcotic consumption, incidences of additional narcotic requirement, and opioid-related side effects were
assessed.
Results The overall mean pain VAS scores among all 44 study subjects were 29 before
surgery, and 58, 47, 40, and 27 at 4, 8, 24, and 48 hours after surgery, respectively. Thirteen
patients needed additional pain rescue despite the multimodal analgesic approach used. No
intergroup differences were observed between the PI and no-PI groups in terms of VAS pain
scores, total narcotic consumption, adjuvant pain rescue incidence, and opioid-related side
effects.
Conclusions Postoperative mean pain VAS scores after volar plating of distal radius fractures
were found to be 58 at 4 hours and 47 at 8 hours. Perifracture site injections were not found
to provide any additional pain control benefit. (J Hand Surg 2010;35A:17871794. Copyright 2010 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic II.
Key words Distal radius fracture, volar plating, postoperative pain, pain control.

From the Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam,
Korea.
Received for publication March 2, 2010; accepted in revised form July 19, 2010.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.

Corresponding author: Hyun Sik Gong, MD, PhD, Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong,
Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea; e-mail: hsgong@snu.ac.kr.
0363-5023/10/35A11-0008$36.00/0
doi:10.1016/j.jhsa.2010.07.023

ASSH Published by Elsevier, Inc. All rights reserved. 1787

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POSTOPERATIVE PAIN AFTER VOLAR PLATING

is the most common

fracture encountered in the upper extremity,
and it represents a public health concern, particularly in the elderly.1 Recently, volar plating has
become a popular treatment because this procedure
makes it easier to obtain and maintain fracture reduction, and it enables the patients to resume activities of
daily living earlier than those treated nonsurgically.1,2
Volar plating provides stable fixation and enables
motion exercises to be undertaken early after surgery, which might be beneficial for early functional recovery. On the other hand, postoperative
pain can discourage the early initiation of exercise,
decrease patient satisfaction, and result in poor
clinical outcome due to delayed rehabilitation.3,4
Although increasing numbers of volar plating surgery after distal radius fracture have been performed, few studies have assessed the management
of pain in the early postoperative period.5
Various methods are used to manage pain after orthopedic surgery. These methods include conventional
nonsteroidal anti-inflammatory drugs or opioids,6 regional or peripheral nerve block techniques,7 and the
administration of wound infiltrating and intra-articular
local anesthetics.8,9 Although opioids still play a major
role, their use during the postoperative period might
increase the risk of adverse effects such as nausea and
vomiting, respiratory depression, sedation, pruritus, urinary retention, and sleep disturbances.10-12 To reduce
opioid-related side effects and improve analgesia by
using synergisms between analgesics, a multimodal analgesia technique was introduced and has since been
reported to shorten hospitalization times, improve functional recovery, and decrease health care costs after
orthopedic surgery.8,10 In particular, periarticular or intra-articular injections after arthroplasty or arthroscopy
have been shown to control postoperative pain effectively and are easily administered with low side-effect
rates.9,13-15
Although several studies have addressed postoperative pain control after orthopedic procedures, including
total joint arthroplasty, few studies have been conducted on pain levels or pain control after the volar
plating of distal radius fractures. In this study, we evaluated early postoperative pain levels after the volar
plating of distal radius fractures performed under regional anesthesia and determined whether local injections of ropivacaine, morphine, and epinephrine into the
joint, ligament, periosteum, subcutaneous tissue, and
skin, and around interosseous and superficial radial
nerves (as an additional sensory nerve block) provide
additional pain management benefits. We hypothesized

ISTAL RADIUS FRACTURE

TABLE 1. Patient Data

Both
Groups
Number

No-PI
Group

p
PI Group Value

44

22

22

13/31

7/15

6/16

59 12

61 14

57 10

.86

Time to surgery (d) 2.8 1.6 2.6 1.7 2.9 1.6

.73

Gender (M/F)
Age (y)
Surgery time (min)

44 7

43 9

46 6

.52

.90

Fracture type
A2

11

.73

A3

.99

B3

.99

C1

11

.73

C2

.99

C3

.99

that local perifracture site injection and an additional

sensory block with long-acting anesthetic might provide additional pain management benefits without impairing the important protective sensory functions and
motor functions to start finger motion exercises after
surgery.
PATIENTS AND METHODS
Patients
After obtaining approval from our institutional review
board, informed consent was obtained from 44 consecutive patients who had volar plating for a distal radius
fracture between March 2008 and April 2009. There
were 13 men and 31 women with an average age of 59
years (range, 16 89 y) (Table 1). We included patients
with a distal radius fracture without a styloid fracture or
with a styloid fracture not requiring surgery. The surgical criteria were as follows (only one criterion was
needed): (1) radial shortening more than 5 mm, (2)
dorsal angulation more than 10 or volar angulation
more than 20, (3) radial inclination less than 10, and
(4) articular stepoff more than 2 mm, after closed reduction at the emergency room or when the patient was
followed up at the outpatient clinic 1 to 2 days after
trauma. We excluded those with multiple injuries, neurovascular injuries, a combined distal radioulnar joint
instability, associated carpal instability or a large ulnar
styloid fragment requiring fixation, those who regularly
used narcotics, those with a psychiatric illness or a
known allergy or contraindication to opiates or local
anesthetics, and those whose surgery occurred after one
week. The average time from onset of trauma to date of

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POSTOPERATIVE PAIN AFTER VOLAR PLATING

surgery was 2.8 days. The patients in this study were

routinely admitted to our hospital for 2 days in accordance with the usual practice pattern of the authors
health care system in South Korea, where admission
cost is relatively low and patients tend to stay longer at
hospitals, in general.
Surgery and pain control protocol
All patients received a preoperative axillary nerve block
that provided approximately 2 to 3 hours of anesthesia,
using a short-acting anesthetic (lidocaine) administered
with peripheral nerve stimulator (Stimuplex-DIG; B.
Broun, Melsungen, Germany). The anesthetic technique and intensity were controlled by a single, experienced anesthesiologist. All surgeries were performed
by a single, experienced orthopedic surgeon, with an
atraumatic technique that reduced tissue trauma from
surgery by minimizing inappropriate stretching, tearing,
and maceration of the soft tissue and skin. Incision
lengths were controlled, and the standard trans-flexor
carpi radialis approach16 was used in all cases. The
pronator quadratus was completely detached from the
radial insertion. Only one type of volar plating system
(Acumed, Hillsboro, OR) was used throughout the
study. A silicone drain was used routinely to minimize
hematoma formation. The mean duration of surgery,
which was defined as the duration from the skin
incision to the end of skin closure and was documented in the anesthesia record, was 44 7 minutes. After surgery, wrists were immobilized using
a short-arm volar plaster splint, and patients were
encouraged to perform active shoulder, elbow, and
finger motion exercises. At one week after surgery,
all wrists were placed in a removable wrist brace.
Physiotherapy and occupational therapy were
started 2 weeks after surgery. Braces were used for
around 6 weeks, as required.
When surgery was scheduled, patients received acetaminophen 650 mg 3 times per day and oxycodone
Slow-Release (SR) 10 mg as needed as a preoperative,
pre-emptive analgesia. The pain medication taken by
patients before they visited our clinic was not recorded.
After surgery, all patients received postoperative, intravenous, patient-controlled analgesia (PCA) for 24 hours
(fentanyl 0.2 g/mL/kg, ketorolac 0.02 mg/mL/kg, and
ondansetron 0.08 mg/mL at 1 mL/h, a bolus use of 1
mL, and a lockout interval of 15 min). All patients
received oxycodone SR 20 mg every 12 hours and
acetaminophen 650 mg 3 times per day as postoperative
medications for 7 days and acetaminophen 650 mg up
to 3 times per day thereafter. Oral nonsteroidal antiinflammatory drugs were avoided because of their ef-

1789

fects on inflammation and local immune responses,

which could affect wound healing in the perioperative
setting, although ketorolac was used in the PCA for 24
hours.17
Perifracture site local injections
To evaluate whether perifracture site local injections
(PI) had pain management benefits, patients were randomly allocated to 2 groupsthat is, the PI and no-PI
groups using a randomization table. Members in the
PI group received intraoperative perifracture site local
infiltration and additional sensory nerve blocks just
before skin closure. For perifracture site local infiltration and additional sensory block, local analgesic solution was injected into the wrist joint, joint capsule,
periosteum, subcutaneous tissue, skin, and around the
anterior and posterior interosseous nerves and the superficial radial nerve. A volume of 2 mL each was
injected into the joint capsule and periosteum and 3 mL
each into the wrist joint, subcutaneous tissue, skin, and
around the passage of each nerve (anterior interosseous
nerve, posterior interosseous nerve, and superficial radial nerve), making the total amount injected 22 mL.
The anterior interosseous nerve was blocked in the
course of the pronator quadratus and posterior interosseous nerve in the fourth dorsal extensor compartment. The terminal branches of the anterior and posterior interosseous nerves are considered to have
nociceptive axons arising from the wrist, and denervation of the wrist joint has been suggested to be a simple
and fast pain control modality that provides satisfactory
results in some degenerative diseases.18,19 The mixture
of anesthetics consisted of 2 ampules of ropivacaine
HCL (Naropin, 0.75%, 7.5 mg/mL, 20 mL/ampule;
Astrazeneca, London, UK), 1 ampule of morphine sulfate (5 mg/0.5 mL, 0.5 mL/ampule), 1 ampule of epinephrine HCL (1 mg/mL, 1 mL/ampule) and normal
saline 20 mL; thus, the total volume of anesthetic mixture was 61.5 mL. The usual concentration of epinephrine for the purpose of increasing the effect of local
anesthetics is 5 to 20 g/mL.20 The concentration of 1
ampule of epinephrine (1 mg) in 61.5 mL is 0.016
mg/mL (16 g/mL), which is in the proper range. The
concentration of morphine sulfate (5 mg/61.5 mL) was
higher than that used in a study by Khoury et al.,21 in
which 1 mg morphine sulfate in 20 mL 0.25% bupivacaine (1 mg/20 mL) produced an analgesic effect of as
long as 2 days after surgery. Ropivacaine is similar to
bupivacaine in terms of onset, duration, and extent of
sensory block, with a 120- to 280-minute duration for
local infiltration and a 240- to 480-minute duration as a
single nerve block in epinephrine-containing solution,

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POSTOPERATIVE PAIN AFTER VOLAR PLATING

but it has a greater margin of safety and fewer central

nervous system and cardiac toxicities than bupivacaine.22 Its efficacy as an intra-articular injection for
multimodal, postoperative pain control has been demonstrated.23 In this study, we injected 22 mL of the total
61.5 mL anesthetic mixture. Therefore, the dose of
ropivacaine was 107.3 mg (300 mg 22/61.5). Chondrolysis has been reported to occur after intra-articular
injection of anesthetics, but it seems to be related to a
longer infusion duration and higher dose (48 to 72 h of
continuous catheter infusion of bupivacaine, with a total
amount of more than 500 mg).24 Furthermore, ropivacaine was recently noted to be less chondrotoxic than
bupivacaine in an in vitro human articular chondrocyte
study.22 As we used only 3 mL of the solution (15 mg
ropivacaine, 300 mg 3/61.5) for a single injection
into the joint, the risk of chondrolysis seems minimal.
Evaluation and analysis
Patients were asked to rate pain using a 100-mm visual
analog scale (VAS) ruler25 before surgery when they
took the pre-emptive analgesics (oxycodone SR), and at
4, 8, 24, and 48 hours after surgery. To exclude the
effect of regional anesthetics of brachial plexus block, a
short-acting anesthetic (lidocaine) was used, which provided approximately 2 to 3 hours of anesthesia, and
immediate postoperative pain levels were excluded. After surgery, all patients were routinely checked for their
vital signs and neurologic status by nurses every hour
until full neurologic recovery was confirmed. The
nurses checked the neurologic status by ordering patients to flex and extend the fingers and asking whether
sensations of the fingers are the same as the opposite
side. All patients were considered to have a complete
motor and sensory recovery within 3 hours after surgery, as confirmed by the nurses charts. Pain VAS
ratings were determined by a single evaluator (research
assistant) unaware of patient allocation throughout the
study period, except for occasions when the 8-hour
evaluation should be done late in the evening, in which
case it was done by a resident.
When a VAS score was more than 70 or the patient
concerned requested extra analgesics after pushing the
button for extra infusion of the intravenous PCA medicine, the evaluator notified a physician, and 50 mg
meperidine was administered intravenously and recorded. At the same time, trained nurses recorded details of systemic, postoperative side effects. Total
amount of opioid consumption was calculated by converting meperidine doses into fentanyl equivalents,
based on an equianalgesic ratio of 75 mg meperidine to
0.1 mg fentanyl.26,27

Prospective power analysis determined that 22 patients were needed in each group to demonstrate a 20%
difference in pain severity between the 2 groups at an
level of 0.05 and a value of 0.80. The Students t-test
was used to determine the significances of group differences in continuous variables and the chi-square or
Fishers exact test was used to determine the significance of differences between categorical variables. Correlation analysis was done to determine whether the
preoperative pain levels were related to the postoperative values. Statistical significance was accepted for p
values of .05.
RESULTS
Pain VAS score
The mean preoperative pain VAS score ( SD) was
29 18 among all 44 study subjects. After surgery, the
overall mean pain VAS scores ( SD) were 58 21,
47 19, 40 21, and 27 22 at 4, 8, 24, and 48 hours
after surgery, respectively. There was no significant
relationship between the preoperative pain levels and
the 4-hour postoperative values (p .112).
Patients in the no-PI group who received intravenous
PCA alone after an axillary nerve block achieved mean
pain VAS scores ( SD) of 56 23, 40 26, 32 24,
and 27 26 at 4, 8, 24, and 48 hours after surgery,
respectively, and patients in the PI group achieved
mean pain VAS scores ( SD) of 60 21, 58 19, 49
21, and 26 22, respectively, at these times. No
significant intergroup differences in the mean pain VAS
scores were observed at 4 and 48 hours after surgery,
but scores in the PI group were significantly higher than
no-PI group scores at 8 and 24 hours after surgery (p
.025, p .037, respectively, Fig. 1).
Total amount of PCA consumption, additional pain rescue,
and side effects
The average total amount of PCA consumption was
33.3 5.3 mL, which is about 398.7 64 g of
fentanyl (Table 2). Thirteen of the 44 patients needed
additional pain rescue despite the multimodal analgesic
approach used, the majority during the early postoperative period (up to 4 hours after surgery). Fourteen
patients complained of opioid-related side effects, such
as nausea, vomiting, or dizziness, during the 48-hour
postoperative observation period, and most opioid-related symptoms were resolved within 24 hours.
The average total amount of PCA consumption was
32 4.7 mL in patients in the no-PI group and 34
5.2 mL in the PI group. Eight patients in the PI group
and 5 patients in the no-PI group required additional
pain rescue (Fig. 2), and the total amount of opioid

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POSTOPERATIVE PAIN AFTER VOLAR PLATING

FIGURE 1: Postoperative VAS pain scores after volar plating. No significant intergroup differences in the mean VAS pain scores
were observed at 4 or 48 hours after surgery, but scores in the PI group were significantly higher than the no-PI group scores at 8
and 24 hours after surgery (Students t-test).

TABLE 2.

Comparison of Parenteral Opioid Consumption

Both Groups

Mean PCA consumption (mL)

Total narcotic (fentanyl) consumption (g)*

33.3
437.6

No-PI Group
32 4.7
429.6 60.2

PI Group
34 5.2
445.6 64.5

p Value
.88
.80

*Calculated by converting meperidine doses into fentanyl equivalent based on an equianalgesic ratio of 75 mg meperidine to 0.1 mg fentanyl.

consumption was 429.6 60.2 g fentanyl in the no-PI

group and 445.6 64.5 g fentanyl in the PI group.
Nine patients in the PI group and 5 patients in the no-PI
group experienced nausea, vomiting, or dizziness (Fig. 3).
However, no significant differences were observed
between the 2 groups in terms of PCA consumption
or total narcotic consumption (p .88, p .80,
respectively) or between patients requiring additional
pain rescue or reporting side effects at any postoperative time point (p .32, p .20, respectively).
No patient had difficulties in beginning finger range
of motion exercise one day after surgery associated
with postoperative pain.
DISCUSSION
Studies regarding early postoperative pain after open
distal radius fracture repair have been rare. This study
demonstrates that patients who have had volar plate
fixation for a distal radius fracture under regional block
experience considerable postoperative pain, even under
a multimodal pain control protocol including intravenous PCA and local injections.

Early postoperative pain VAS scores after total hip

or knee arthroplasty or arthroscopic shoulder surgery
under a nerve block have been reported to range between 30 and 60.13,14,28-31 Although the duration of
intense pain (VAS score 50) was shorter than that of
joint replacement surgery, which continued for 24 hours
after surgery,14,28-31 the pain scores encountered during
the present study were higher than we expected because
the procedure is considered simpler, and dissection and
surgical times are shorter than those of total joint replacement surgery. We believe that postoperative pain
after volar plating might be underestimated or accepted
by patients and physicians because it is considered that
postoperative pain is unavoidable after fracture surgery,
which contrasts with the elective surgery setting, such
as after total joint arthroplasty. Our results concur with
those of Rawal et al.,5 who noted that 36% of patients
who had ambulatory hand surgery experienced moderate to severe pain after surgery despite analgesic medication. These authors also emphasized the need for
better analgesic techniques in these patients. Although
the patients in our study had greater than expected

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POSTOPERATIVE PAIN AFTER VOLAR PLATING

FIGURE 2: Incidence (percentage of patients) of additional pain medication requirements. In all, 36% (8/22) of patients in the PI
group and 23% (5/22) patients in the no-PI group required additional pain rescue, but no significant differences were observed
between the 2 groups in numbers of patients requiring additional pain rescue at any postoperative time point (Fishers exact test).

FIGURE 3: Incidence (percentage of patients) of opioid-related side effects. In all, 41% (9/22) of patients in the PI group and 23%
(5/22) of patients in the no-PI group experienced nausea, vomiting, or dizziness, but no significant differences were observed
between the 2 groups in numbers of patients reporting side effects at any postoperative time point (Fishers exact test).

postoperative pain, this is not a reason for admitting

patients to the hospital; outpatient surgery is widely
accepted for this procedure and is cost effective. Nonetheless, pain control should be improved regardless of
the postoperative setting.
Perifracture site local infiltration and additional sensory nerve blocks were not found to provide any additional pain control benefit in the present study. Published results on local injections are contradictory, and

some studies have concluded that multimodal analgesic

techniques have opioid-sparing effects but do not reduce opioid-related side effects.32,33 We initially believed that additional blocks of the superficial radial and
interosseous nerves, using a long-acting anesthetic,
would provide a more sustained sensory block on the
fracture site without impairing the important protective
sensory functions of the median or ulnar nerve, or the
motor functions required to start finger motion exer-

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POSTOPERATIVE PAIN AFTER VOLAR PLATING

cises after surgery. However, these expected effects

were not observed, which might be because the effect of
perifracture injection was masked by brachial plexus
block in the early postoperative 3 hours. Furthermore,
the high pain VAS scores observed at 8 and 24 hours
after surgery in the PI group could be due to the socalled rebound pain phenomenon, which has been
shown to occur when the effects of a perineural single
injection or continuous infusion resolve.34 Williams et
al. emphasized the importance of rebound pain after
anterior cruciate ligament reconstruction and reported
that it can be controlled by increasing nerve block
duration.34 In addition, the volume effect of the injection could have caused increased pain in the swollen
wrist.
This study has several limitations. First, we lacked
follow-up pain levels or data regarding side effects
beyond 48 hours after surgery, which would have provided a better understanding of the temporal course of
pain. Second, pharmacokinetics and effective dose of
locally administered opioid have not been properly established. Therefore, our drug regimen might not be
optimal, although it was determined from previous
studies on knee or hip joint surgery.14,28,29 Third, we
did not evaluate the effectiveness of the local injections
around the nerves. Although we often found that anesthesia of the first dorsal web space continued after
recovery of the axillary nerve block, we did not record
the anesthetic effect of the local injections. Therefore,
variations of the anesthetic intensity of the local injections might have affected the pain levels. Finally, although the axillary block anesthetic technique and intensity was controlled by a single, experienced
anesthesiologist, and all patients had sensory and motor
recovery within 3 hours after surgery, potential variation of anesthetic intensity might have affected postoperative pain intensities. Future study with patients who
have surgery with general anesthesia will exclude the
effect of axillary block and better demonstrate the time
course of pain and the effect of local injections.
In our patients and setting, postoperative pain levels
after the volar plating of distal radius fractures were
found to be considerably high (a VAS score of 58 at 4
hours and 47 at 8 hours after surgery), although the
duration of intense pain was relatively short. The
present study showed that perifracture site local injections do not offer additional pain control benefits. In
view of the increasing popularity of volar plating and
the short hospital stay, further studies might be needed
to develop techniques that achieve better control of
postoperative pain after volar plating for distal radius
fractures.

1793

REFERENCES
1. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States
in the treatment of distal radial fractures in the elderly. J Bone Joint
Surg 2009;91A:1868 1873.
2. Ring D, Jupiter JB. Treatment of osteoporotic distal radius fractures.
Osteoporos Int 2005;16(Suppl 2):S80 S84.
3. Slutsky DJ, Herman M. Rehabilitation of distal radius fractures: a
biomechanical guide. Hand Clin 2005;21:455 468.
4. Cheing GL, Wan JW, Kai Lo S. Ice and pulsed electromagnetic field
to reduce pain and swelling after distal radius fractures. J Rehabil
Med 2005;37:372377.
5. Rawal N, Hylander J, Nydahl PA, Olofsson I, Gupta A. Survey of
postoperative analgesia following ambulatory surgery. Acta Anaesthesiol Scand 1997;41:10171022.
6. Joris J. Efficacy of nonsteroidal antiinflammatory drugs in postoperative pain. Acta Anaesthesiol Belg 1996;47:115123.
7. Pagnano MW, Hebl J, Horlocker T. Assuring a painless total hip
arthroplasty: a multimodal approach emphasizing peripheral nerve
blocks. J Arthroplasty 2006;21(4 Suppl 1):80 84.
8. Parvataneni HK, Ranawat AS, Ranawat CS. The use of local periarticular injections in the management of postoperative pain after
total hip and knee replacement: a multimodal approach. Instr Course
Lect 2007;56:125131.
9. Ranawat AS, Ranawat CS. Pain management and accelerated rehabilitation for total hip and total knee arthroplasty. J Arthroplasty
2007;22(7 Suppl 3):1215.
10. Joshi GP. Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiol Clin North America 2005;23:185202.
11. Phillips DM. JCAHO pain management standards are unveiled. Joint
Commission on Accreditation of Healthcare Organizations. JAMA
2000;284:428 429.
12. Kehlet H. Postoperative opioid sparing to hasten recovery: what are
the issues? Anesthesiology 2005;102:10831085.
13. Webb D, Guttmann D, Cawley P, Lubowitz JH. Continuous infusion
of a local anesthetic versus interscalene block for postoperative pain
control after arthroscopic shoulder surgery. Arthroscopy 2007;23:
1006 1011.
14. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS,
Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty 2007;22(6
Suppl 2):3338.
15. Middleton F, Coakes J, Umarji S, Palmer S, Venn R, Panayiotou S.
The efficacy of intra-articular bupivacaine for relief of pain following arthroscopy of the ankle. J Bone Joint Surg 2006;88B:1603
1605.
16. Orbay JL, Badia A, Indriago IR, Infante A, Khouri RK, Gonzalez E,
et al. The extended flexor carpi radialis approach: a new perspective
for the distal radius fracture. Tech Hand Up Extrem Surg 2001;
5:204 211.
17. Busti AJ, Hooper JS, Amaya CJ, Kazi S. Effects of perioperative
antiinflammatory and immunomodulating therapy on surgical wound
healing. Pharmacotherapy 2005;25:1566 1591.
18. Foucher G, Long Pretz P, Erhard L. Joint denervation, a simple
response to complex problems in hand surgery. Chirurgie 1998;123:
183188.
19. Schweizer A, von Kanel O, Kammer E, Meuli-Simmen C. Longterm follow-up evaluation of denervation of the wrist. J Hand Surg
2006;31A:559 564.
20. Berde CB, Strichartz GR. Local anesthetics. In: Miller RD, ed.
Millers anesthesia. 7th ed. Philadelphia: Elsevier, 2010:913
940.
21. Khoury GF, Chen AC, Garland DE, Stein C. Intraarticular morphine,
bupivacaine, and morphine/bupivacaine for pain control after knee
videoarthroscopy. Anesthesiology 1992;77:263266.
22. Piper SL, Kim HT. Comparison of ropivacaine and bupivacaine

JHS Vol A, November

1794

23.

24.
25.
26.
27.
28.

29.

POSTOPERATIVE PAIN AFTER VOLAR PLATING

toxicity in human articular chondrocytes. J Bone Joint Surg

2008;90A:986 991.
Oh JH, Kim WS, Kim JY, Gong HS, Rhee KY. Continuous intralesional infusion combined with interscalene block was effective for
postoperative analgesia after arthroscopic shoulder surgery. J Shoulder Elbow Surg 2007;16:295299.
Hansen BP, Beck CL, Beck EP, Townsley RW. Postarthroscopic
glenohumeral chondrolysis. Am J Sports Med 2007;35:1628 1634.
Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;
2:175184.
Bond BS. Equianalgesia: applying evidence-based practice guidelines. Clin J Oncol Nurs 2008;12:527529.
Twycross RG. Opioids. In: Wall PD, Melzack R, ed. Textbook of
pain. 4th ed. Philadelphia: Churchill Livingstone, 1999:1198 1208.
Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ,
Bourne RB, et al. Efficacy of periarticular multimodal drug injection
in total knee arthroplasty. A randomized trial. J Bone Joint Surg
2006;88A:959 963.
Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tonnesen EK,

30.

31.

32.
33.
34.

Soballe K. Comparison of peri- and intraarticular analgesia with

femoral nerve block after total knee arthroplasty: a randomized
clinical trial. Acta Orthop 2007;78:172179.
Krenzel BA, Cook C, Martin GN, Vail TP, Attarian DE, Bolognesi
MP. Posterior capsular injections of ropivacaine during total knee
arthroplasty: a randomized, double-blind, placebo-controlled study. J
Arthroplasty 2009;24(Suppl 6):138 143.
Fu P, Wu Y, Wu H, Pi X, Qian Q, Zhu Y. Efficacy of intra-articular
cocktail analgesic injection in total knee arthroplastya randomized
controlled trial. Knee 2009;16:280 284.
Jin F, Chung F. Multimodal analgesia for postoperative pain control.
J Clin Anesth 2001;13:524 539.
Kehlet H, Wilmore DW. Multimodal strategies to improve surgical
outcome. Am J Surg 2002;183:630 641.
Williams BA, Bottegal MT, Kentor ML, Irrgang JJ, Williams JP.
Rebound pain scores as a function of femoral nerve block duration
after anterior cruciate ligament reconstruction: retrospective analysis
of a prospective, randomized clinical trial. Reg Anesth Pain Med
2007;32:186 192.

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