eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fracture, Elbow: Treatment & Medication
Updated: Mar 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
- Emergency physicians need to do a thorough neurovascular examination as well as evaluate for concurrent injuries.
- Provide adequate analgesia to achieve patient comfort in the ED.
- Proper immobilization for the various types of elbow fractures is indicated.
- Assess whether the patient needs orthopedic evaluation in the ED, admission to the hospital for observation, or if discharge and follow up with an orthopedic surgeon is adequate.
Consultations
- All elbow fractures should be referred for orthopedic follow-up.
- Urgent orthopedic consultation in the ED is required in the following situations:
- If an open fracture or an open joint is suspected
- If the injury poses a significant risk of neurovascular injury such as a displaced supracondylar fracture
Medication
Drugs used to treat fractures are generally NSAIDs, analgesics, and anxiolytics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.
Nonsteroidal anti-inflammatory agents (NSAIDs)
These drugs are used commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.
Adult
200-400 mg PO q4-6h prn; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients on anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 5-7 mg/kg/dose PO q8-12h prn
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with fractures.
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
<12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d
>12 years: 10-15 mg/kg/dose acetaminophen q4-6h prn; not to exceed 2.6 g/d of acetaminophen
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24h of acetaminophen; higher doses may cause liver toxicity
Anxiolytics
Patients with painful injuries usually experience significant anxiety. Anxiolytics allow a smaller analgesic dose to achieve the same effect.
Lorazepam (Ativan)
Sedative hypnotic in benzodiazepine class that has a short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation.
Excellent for sedating patient for longer than 24-h period.
Monitor patient's BP after administering dose and adjust as necessary.
Adult
Initial dose: 2 mg total or 0.044 mg/kg IV, whichever is smaller
Pediatric
0.05-0.1 mg/kg IV slowly q2-5min; may repeat dose of 0.05 mg/kg IV slowly
Alcohol, phenothiazines, barbiturates, and MAOIs increase CNS toxicity
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Antibiotics
These agents are given as prophylaxis to patients with open fractures.
Cefazolin (Ancef)
Used along with gentamicin for prophylaxis in patients with open fractures. First-generation semisynthetic cephalosporin that by binding to 1 or more penicillin-binding proteins arrests bacterial cell wall synthesis and inhibits bacterial replication. Poor capacity to cross blood-brain barrier. Primarily active against skin flora, including S aureus. Typically used alone for skin and skin-structure coverage. IV and IM dosing regimens are similar.
Adult
1 g IV/IM q6-8h
Pediatric
25-100 mg/kg/d IV/IM divided q6-8h depending on severity of infection; not to exceed 6 g/d
Probenecid prolongs effect of cefazolin; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test results for glucose
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Gentamicin (Gentacidin, Garamycin)
Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Dosing regimens are numerous and adjusted based on renal function (CrCl) and changes in volume of distribution. Dose may be given IV/IM.
Adult
1.5 mg/kg/dose IV q8-24h; not to exceed 80 mg; may need dosage adjustment in patients with renal impairment
Pediatric
<5 years with normal renal function: 2.5 mg/kg/dose q8h IV/IM
>5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d q8h; not to exceed 300 mg/d, with adjustments for renal function prn; monitor levels as in adults
Other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; enhances effects of neuromuscular blocking agents and thus may cause prolonged respiratory depression; loop diuretics may increase auditory toxicity—possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Toxoid
This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.
Tetanus toxoid
Induces active immunity against tetanus in selected patients. Immunizing DOC for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh, lateral.
Adult
Primary immunization: 0.5 mL IM, give 2 injections q4-8 wk apart and a third dose q6-12 mo after second injection
Booster dose: 0.5 mL q10y
Pediatric
Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)
Documented hypersensitivity; history of any type of neurological symptoms or signs following administration of this product
FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended
Immunoglobulins
Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.
Tetanus immune globulins (Hyper-Tet)
For passive immunization of any person with a wound that may be contaminated with tetanus spores.
Adult
For prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid
For clinical tetanus: 3,000-10,000 U IM
Pediatric
For prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
For clinical tetanus: 3,000-10,000 U IM
None reported
Because antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live-virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications since usually incompatible
More on Fracture, Elbow |
| Overview: Fracture, Elbow |
| Differential Diagnoses & Workup: Fracture, Elbow |
 Treatment & Medication: Fracture, Elbow |
| Follow-up: Fracture, Elbow |
| Multimedia: Fracture, Elbow |
| References |
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References
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Gupta R. Intercondylar fractures of the distal humerus in adults. Injury. Oct 1996;27(8):569-72. [Medline].
Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King RE, ed. Fractures in Children. 4th ed. Philadelphia: JB Lippincott; 1996:653.
Brown IC, Zinar DM. Traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children. J Pediatr Orthop. Jul-Aug 1995;15(4):440-3. [Medline].
Geiderman JM. Humerus and elbow. In: Marx JA. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia: Mosby; 2006:Chap 49.
Harris IE. Supracondylar fractures of the humerus in children. Orthopedics. Jul 1992;15(7):811-7. [Medline].
Nicholson DA, Driscoll PA. ABC of emergency radiology. The elbow. BMJ. Oct 23 1993;307(6911):1058-62. [Medline].
Skaggs D, Pershad J. Pediatric elbow trauma. Pediatr Emerg Care. Dec 1997;13(6):425-34. [Medline].
Shearman C, el-Khoury GY. Pitfalls in the radiologic evaluation of extremity trauma: Part 1. The upper extremity. Am Fam Physician. 1998;58:1298. [Medline].
Karlsson MK, Hasserius R, Karlsson C, et al. Fractures of the olecranon: a 15- to 25-year followup of 73 patients. Clin Orthop. Oct 2002;205-12. [Medline].
Steinberg G, Adkins C, Baran D. Orthopaedics in Primary Care. 2nd ed. Williams & Wilkins; 1992:62-85.
Roust AF, Bredenkamp JH, Uehara DT. Injuries to the elbow and forearm. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw Hill Text; 2003:1691-1694.
Further Reading
Keywords
elbow fracture, broken bone, broken arm, broken elbow, elbow pain, fracture treatment, fracture symptoms, elbow dislocation, radial head fracture, olecranon fracture, supracondylar fracture, intercondylar fracture, epicondyle fracture, medial epicondyle fracture, lateral epicondyle fracture, condyle fracture, medial condyle fracture, lateral condyle fracture, trochlea fracture, capitellum fracture
