Ankle Fracture 

Updated: Oct 26, 2016
Author: Kara Iskyan, MD; Chief Editor: Trevor John Mills, MD, MPH 

Overview

Background

The ankle joint is composed of 2 joints: the true ankle joint and the subtalar joint. Ankle fractures refer to fractures of the distal tibia, distal fibula, talus, and calcaneus. The true ankle joint contains the tibia (medial wall), fibula (lateral wall), and talus (the floor upon which the tibia and fibula rest). The true ankle joint allows dorsiflexion and plantar flexion or the "up and down" movement of the ankle. The foot can be made to point toward the floor or toward the ceiling via the true ankle joint.

The subtalar joint consists of the talus and the calcaneus. The subtalar joint allows the foot to be inverted or everted, that is, the sole of the foot can be made to face inward (inverted) or face outward (everted) through the subtalar joint.

During evaluation of ankle fractures, the mechanism of injury (eg, eversion, inversion, dorsiflexion, plantar flexion), associated injuries (eg, vascular, ligamentous, capsular), the need for immobilization (eg, application of a splint), and the need for referral to a specialist for further treatment or evaluation (eg, additional immobilization, surgery, or rehabilitation) are all important components of care.

For more information on fractures, see Medscape's Fracture Resource Center.

Pathophysiology

The primary motion of the ankle at the true ankle joint (tibiotalar joint) is plantarflexion and dorsiflexion. Inversion and eversion occur at the subtalar joint.

Excessive inversion stress is the most common cause of ankle injuries for 2 anatomic reasons. First, the medial malleolus is shorter than the lateral malleolus, allowing the talus to invert more than evert. Second, the deltoid ligament stabilizing the medial aspect of the ankle joint offers stronger support than the thinner lateral ligaments. As a result, the ankle is more stable and resistant to eversion injury than inversion injury. However, when eversion injury occurs, there is often substantial damage to bony and ligamentous supporting structures and loss of joint stability.

Posterior malleolar fractures are usually associated with other fractures and/or ligamentous disruption. They are commonly associated with fibular fractures and are often unstable.

Transverse malleolar fractures usually represent an avulsion-type injury. Vertical malleolar fractures result from talar impaction.

Epidemiology

Of all the ankle injuries evaluated in the ED, only 15% are ankle fractures. The frequency of ankle fractures has been increasing for the past 20 years, and the rate is approximately 187 in 100,000 person-years.

Mortality/Morbidity

Patients with unrecognized or undertreated open ankle fractures are at high risk of infection including local infection, osteomyelitis, and sepsis. Gas gangrene is the most serious infectious complication. It can be both limb and life threatening.

Vascular supply to the ankle and foot may become compromised by development of a compartment syndrome or direct injury to blood vessels from bone fragments.

Talus fractures, those commonly occurring in snowboarding trauma, can cause osteoarthritis and subtalar joint degeneration.

A calcaneal fracture may compromise inversion and eversion of the ankle. Surgical complications and prolonged rehabilitation are common with calcaneal fractures.

Older patients with ankle fractures experience more long-term complications than younger patients.

Age and Sex

The male-to-female ratio for ankle fracture is 2:1. Most patients younger than 50 years are male, while most older than 50 years are female.

In children, ankle fractures have an incidence of 1 in 1000 per year.[1] Pediatric ankle bones are susceptible to medial malleolar and transitional fractures of the distal tibia.

As the population ages, ankle fractures are becoming more common. An increase in fall risk and osteoporosis are risk factors.

Prognosis

The prognosis can be improved with prompt, accurate diagnosis and appropriate treatment and referral.

Complex open fractures with substantial soft-tissue damage have a worse prognosis than isolated closed ankle fractures.

Isolated, nondisplaced lateral malleolus fracture, the most common ankle fracture, has a favorable prognosis and heals unremarkably.

Aggressive rehabilitation helps reduce the majority of morbidity associated with ankle fractures.

Patient Education

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education article Broken Ankle (Ankle Fracture).

 

Presentation

History

All injured patients should be evaluated for more extensive and serious trauma depending on the circumstances.

Knowledge of the trauma, such as the direction of torque force applied to the ankle and the foot's position, helps predict the nature and severity of an ankle injury. Although patients tend to recall the event, they often cannot depict the exact manner in which their injury occurred.

History of prior trauma to the affected ankle may cause antecedent laxity, instability, or radiographic abnormalities misinterpreted as an acute event.

Chronic medical condition, such as diabetes, peripheral vascular disease, and metabolic bone disease, may affect examination findings and treatment plans.

Chronic medication use is an important part of the history and has implications for management. For example, long-term use of corticosteroids may provoke premature osteoporosis, whereas nonsteroidal anti-inflammatory drugs (NSAIDs) may mitigate the degree of swelling normally expected with fractures.

Physical

Because an ankle fracture often presents with symptoms similar to those of an ankle sprain, a complete and thorough examination of the involved extremity is needed to avoid misdiagnosis and prevent unnecessary radiographs.

Indicators suggesting fracture include gross deformity, swelling (especially perimalleolar), bony tenderness, discoloration, and ecchymosis. Inability to bear weight on the injured foot also indicates a fracture.

Corroborate any visible deformity by gently manipulating the affected area.

Inspect carefully for the presence of open wounds close to the injured ankle.

Assess the neurovascular status of the foot and ankle. Compare findings to the unaffected extremity.

  • Check presence and quality of pulse of the posterior tibial artery. A hand-held Doppler can be useful to document arterial patency.

  • Check presence and quality of pulse of dorsalis pedis artery. Note that the dorsalis pedis is congenitally absent in as many as 10-15% of the population.

  • Document the time for capillary refill.

Palpate for focal bony tenderness, especially along the medial and lateral malleoli and posterior aspect of the joint. If possible, palpate the most tender area last.

Assess passive and active range of motion of the ankle joint, noting limitations. During the immediate acute phase, most patients' ankles are too tender to cooperate with stress testing of the joint.

Examine the ipsilateral knee and foot, particularly documenting the condition of the proximal fibula and proximal fifth metatarsal.

Causes

Multiple classification schemes are used for ankle fractures. The Lauge-Hansen system categorizes ankle fractures based on the position of the foot and the forces acting on it at the time of injury,[2] while the Danis-Weber system relies on the level of fibular fracture. Neither classification scheme has been proven to be prognostic,[3] so emergency medicine physicians usually label ankle fractures according to the number of fractures in the ankle (unimalleolar, bimalleolar, trimalleolar).

Danis-Weber classification

These fractures are classified according to location of the fracture and appearance of the fibular component. To some degree, Weber classification correlates with need for operative stabilization. Orthopedic surgeons frequently use this classification system:

  • Type A depicts a transverse fibular avulsion fracture, occasionally with an oblique fracture of the medial malleolus. These result from internal rotation and adduction. These are usually stable fractures.

  • Type B describes an oblique fracture of the lateral malleolus with or without rupture of the tibiofibular syndesmosis and medial injury (either medial malleolus fracture or deltoid rupture). These result from external rotation. These may be unstable.[4]

  • Type C designates a high fibular fracture with rupture of the tibiofibular ligament and transverse avulsion fracture of the medial malleolus. Usually, syndesmotic injury is more extensive than in type B. These result from adduction or abduction with external rotation. These are usually unstable and require operative repair.

Pilon fracture

A pilon fracture designates a fracture of the distal tibial metaphysis combined with disruption of the talar dome. An axial loading mechanism drives the talus into the tibial plafond (the distal articular surface of the tibia). A common method of trauma is a foot braced against a floorboard in an auto collision. Skiers coming to an unexpected sudden stop and victims of free fall from heights also may sustain pilon fractures. Incidence of pilon fractures ranges from 1-10% of all tibial fractures. A pilon fracture is shown in the radiograph below.

Pilon fracture in a 35-year-old man who fell 20 ft Pilon fracture in a 35-year-old man who fell 20 ft. Anteroposterior radiograph shows at least 2 fracture lines extending to the articular surface (plafond) of the tibia.

Establish vascular and integument integrity. Pilon fractures are often open. Skin sloughing is not uncommon. Subsequent edema, fracture blisters, and skin necrosis from the original injury may convert closed fractures to open injuries.

Depending on the trauma, associated injuries include spinal compression fractures (especially of L1) and ipsilateral or contralateral fractures of the os calcis, tibial plateau, pelvis, or acetabulum.

As pilon fractures are often comminuted and open, there is often significant long-term disability.

Maisonneuve fracture

A Maisonneuve fracture, shown in the image below, is defined as a proximal fibular fracture coexisting with a medial malleolar fracture or disruption of the deltoid ligament. Maisonneuve fractures are associated with partial or complete disruption of the syndesmosis.

Maisonneuve injury. Mortise view shows transverse Maisonneuve injury. Mortise view shows transverse fracture of the medial malleolus and widening of the tibiofibular syndesmosis without a fracture of the fibula. This injury is suggestive of a proximal fibula fracture (Maisonneuve fracture).

Treatment of Maisonneuve fractures depends on stability of the ankle mortise.

Tillaux fracture

A Tillaux fracture describes a Salter-Harris (SH) type III injury of the anterolateral tibial epiphysis caused by extreme eversion and lateral rotation of the ankle. Incidence is highest in adolescents, usually those aged 12-14 years, because the fracture occurs after the medial aspect of the epiphyseal plate of the tibia closes but before the lateral aspect arrests. A Tillaux fracture is shown in the radiograph below.[5]

An 11-year-old girl with juvenile Tillaux fracture An 11-year-old girl with juvenile Tillaux fracture. Mortise view shows fracture involving the lateral portion of tibial epiphysis.

Distinguish a Tillaux fracture from a triplane fracture. Triplane fracture is a combination of a SH II and III fracture and is more likely than a Tillaux fracture to require open reduction and internal fixation. A triplane fracture is shown in the radiograph below.

A 13-year-old girl with triplane fracture. Anterop A 13-year-old girl with triplane fracture. Anteroposterior radiograph shows a sagittal component through the distal tibia epiphysis.

Pott fracture

Bimalleolar fractures, termed Pott fractures, involve at least 2 elements of the ankle ring. These fractures should be considered unstable and require urgent orthopedic attention.

Cotton fracture

A trimalleolar, or Cotton, fracture involves the medial, lateral, and posterior malleoli. These fractures are considered unstable and require urgent orthopedic attention.

Snowboarder's fracture

With the popularity of snowboarding in the late adolescent and young adult population, it is likely the emergency physician will come across a fracture of the lateral process of the talus, the so-called snowboarding ankle fracture.[6, 7]

A combination of dorsiflexion and inversion of the ankle produces the lateral talar fracture.

A high index of suspicion should be used in snowboarders who complain of lateral ankle pain with a normal-appearing ankle radiograph. Computed tomography imaging is often required to diagnose a talus fracture.

Hyperplantarflexion variant ankle fracture

The ankle fracture “spur sign” was found to be highly associated with the hyperplantarflexion variant ankle fracture, as determined by assessment of injury radiographs. This fracture is composed of a posterior tibial lip fracture with posterolateral and posteromedial fracture fragments separated by a vertical fracture line. The spur sign is a double cortical density at the inferomedial tibial metaphysis. In this study, the incidence of the hyperplantarflexion variant fracture among all ankle fractures was 6.7% (43/640). The spur sign was present in 79% (34/43) of variant fractures and absent in all nonvariant fractures, conferring a specificity of 100% in identifying variant fractures. Positive predictive value and negative predictive value were 100% and 99%, respectively.[8]

 

DDx

 

Workup

Laboratory Studies

No laboratory studies are necessary in patients with isolated ankle fracture when caused by a plausible mechanism. However, repeated ankle fracture or a fracture caused by simple, low force trauma can require investigation for osteoporosis, Charcot-Marie-Tooth disease, arthritis, connective tissue disease, or peripheral vascular disease.

Imaging Studies

Routinely obtaining radiographs following an ankle injury is not cost-effective because fewer than 15% of affected patients have fractures. Patients without fractures are identified reliably from the physical examination. Ottawa ankle rules provide practical guidelines to select patients for radiographic studies.[9, 10] Diagnostic guidelines are available from the American College of Radiology Appropriateness Criteria for suspected ankle fractures.[11]

Indications for ankle radiographs in patients with acute ankle pain include pain in the ankle region plus one of the following[12] :

  • Bony tenderness at the distal 6 cm of the posterior edge of the medial malleolus

  • Bony tenderness at the distal 6 cm of the posterior edge of the lateral malleolus

  • Inability to bear weight both immediately and in the ED (defined as 4 steps)

  • Confounding variables to the Ottawa rules are (1) underlying neurologic deficit affecting lower limb(s), (2) altered mental status, and (3) multisystem trauma.

Application of the Ottawa Ankle Rules to patients younger than 18 years is controversial. While some advocate the rules can be applied to children old enough to talk and walk, others use the ages 5 or 6 as a cut-off.[13]

Perform a standard 3-view radiographic examination (anteroposterior [AP], lateral, and mortise views) of the ankle. In the mortise view, the foot is rotated approximately 15° internally, allowing better visualization of the ankle mortise. Check radiograph for headset sign (ie, tibia sits atop the talus resembling a headpiece on a receiver). Normally, the space between the cradle and the handle should be equal. Lack of symmetry suggests injury.

The ankle joint usually adheres to the ring axiom (eg, a fracture in one part of the ring often is associated with a second injury). Always look for an associated medial malleolar fracture when a spiral fracture of the fibula proximal to the ankle mortise is seen. A vertical fracture of the medial malleolus is also associated with either a lateral malleolar fracture or rupture of the lateral ligaments.

Accessory ossicles appear frequently adjacent to the medial and lateral malleoli and may mimic fractures. Clinical correlation is important. Accessory ossicles demonstrate well-corticated margins, whereas fracture fragments exhibit less-defined borders.

Radiographic examination of the foot is not required in patients with an isolated ankle complaint. Although there may be an occult fracture of the base of the fifth metatarsal, those should be found with adequately performed ankle radiographs.[14]

Externally rotated lateral radiographic projection can provide surgeons with additional information regarding the presence, size, and displacement of posterior malleolar ankle fractures, according to one study. In this study, posterior malleolar fractures were accurately identified on 86.67% (26 of 30) of standard lateral radiographs and on 100% (30 of 30) of externally rotated lateral radiographs. In addition, surgeons described the fracture with greater precision and had greater interclass correlation coefficient values regarding sagittal plane displacement (0.977 versus 0.939) and percentage of involvement of the tibial plafond (0.972 versus 0.775) with an externally rotated lateral projection, as compared with a standard lateral projection.[15]

ACR Appropriateness Criteria for acute trauma to the ankle includes the following[16] :

  • The use of 3-view (anteroposterior, lateral, and mortise) radiographic evaluation of patients meeting the criteria of the Ottawa ankle rules.
  • Cross-sectional imaging has a limited secondary role primarily as a tool for preoperative planning and as a problem-solving technique in patients with persistent symptoms and suspected of having occult fractures.

CT and MRI imaging studies may be part of outpatient management where imaging features by the other modalities are equivocal.[17]

Advanced imaging is most useful to diagnose talar dome and triplane fractures, distinguish pilon from trimalleolar fractures, and differentiate an accessory ossicle from an avulsion fracture. Occasionally, these tests are used to assess the complexity of the fracture and any associated ligamentous and intra-articular injuries.

A bone scan rarely is indicated emergently. It may be useful for diagnosing and localizing stress fractures, infections, and neoplastic lesions.

A study of patients who presented to an urban level 1 trauma center with acute ankle injuries found that the sensitivity of bedside ultrasonography in detecting foot and/or ankle fractures was 100%  and that the specificity of Ottawa Foot and Ankle Rules increased from 50% to 100% with the addition of ultrasonography. The negative predictive value was 100%, and the positive predictive value was 100%.[18]

Other Tests

Stress radiographs assess the ankle during stress testing; however, results of this test generally do not affect immediate ED management.

 

Treatment

Prehospital Care

Patients with ankle injuries must be evaluated for further trauma.

For an isolated ankle injury, confirm neurovascular status of the concerned limb, decrease pain, and prevent further damage.

  • Cover open fractures with wet sterile gauze.

  • Stabilize the suspected fracture site with a pillow splint, air splint, or bulky Jones dressing before transporting patient. Try to immobilize the ankle in a neutral position if possible but avoid excessive handling. Immobilization helps decrease pain, bleeding, and damage to surrounding soft tissue.

  • Prehospital reduction of a fracture is not advised unless neurovascular compromise is evident (eg, presence of a cool, dusky foot) and a significantly prolonged transport time is anticipated.

Emergency Department Care

First, patients should be evaluated for multisystem trauma. Once additional trauma is excluded, an ankle fracture should be identified as stable or unstable. Unstable fractures include any fracture-dislocation, any bimalleolar or trimalleolar fracture, or any lateral malleolar fracture with significant talar shift.

If neurovascular status of the extremity is compromised, the fracture should be reduced as soon as possible and reduction should be maintained during the healing period with a cast, external fixator, or open reduction and internal fixation (ORIF).

Open fractures should be guarded from further contamination by covering wounds with a wet, sterile dressing secured by loosely wrapped dry sterile gauze. Confirm a current tetanus immunization, administering tetanus immunoglobulin when patients lack immunity and harbor a grossly contaminated wound. Consider antibiotic prophylaxis, administering cefazolin for mild to moderately contaminated wounds and adding an aminoglycoside for highly contaminated wounds. Administer vancomycin and gentamicin if the patient is allergic to penicillin. Leave fracture blisters intact. Once ruptured, blisters are more likely to become contaminated by skin flora.

Unless neurovascular compromise exists, reduction is best deferred to the orthopedic consultant when an unstable ankle fracture is diagnosed.

Closed reduction is accomplished as follows (refer to Dislocation, Ankle for specific techniques): The orthopedic consultant typically reduces ankle fractures. Ankle dislocations are reduced easily, and physicians treating a new fracture should be skilled in their initial management; however, immediate reduction of a dislocation may not be required unless blood flow to the foot is compromised. Provide either local anesthesia with a hematoma block[19] or procedural sedation. Closed reduction is best achieved by manipulating the limb to reverse the direction of the original deforming forces. For example, a fracture-dislocation resulting from abductive stress requires pushing the affected site in an adduct direction to restore. Applying a concurrent distracting force often assists reduction attempts.

Simple, uncomplicated lateral malleolar fractures usually can be splinted in the ED, followed by arrangement of timely orthopedic follow-up care. Bimalleolar, trimalleolar, and pilon fractures necessitate urgent orthopedic attention for possible ORIF.

Oral analgesics should be used liberally as long as they do not interfere with other medication or the patient's ability to ambulate. The emergency physician might consider prescribing a narcotic because controversy exists whether NSAIDs impair fracture and ligament healing.

Admission criteria include open fracture, unstable fracture requiring urgent operative stabilization, and the presence of or potential for neurovascular compromise (eg severely comminuted pilon fracture causing a compartment syndrome).

Splinting and casting

Ankle splints  (also see Splinting, Ankle) are commercially available or may be constructed by sandwiching 10-12 layers of plaster between 4 sheets of cotton padding.

Posterior splint: Stable injuries can be treated initially with a posterior splint. Ask the patient to lie prone with the knee bent to a 90-degree angle when applying a posterior splint. Extend the splint from the metatarsal heads along the posterior surface of the leg to the level of the fibular head. Maintain the ankle at a 90-degree angle and mold the splint in the malleolar region.

Sugar tong/short leg stirrup splint: An alternative to the posterior splint is a sugar tong or short leg stirrup splint. Using 4- or 6-inch plaster, pass the splint under the plantar aspect of the foot, between the calcaneus and metatarsal heads. Secure in place with an elastic wrap.[20]

Splinting of a fracture with bulky padding (eg, Jones dressing) is indicated when immobilization and compression are needed but swelling is expected to progress. In very unstable ankle fractures, apply a bivalve cast. A normal cast is bivalved by cutting completely through the casting material on the medial and lateral aspects longitudinally to avoid extremity compression. Next, the bivalved cast is overwrapped with an elastic bandage to stabilize the fracture site, while still allowing for swelling and expansion.

Consultations

Request orthopedic consultation for the following conditions:

  • Displaced medial, lateral, or posterior malleolar fracture

  • Medial malleolar fracture with lateral ligament damage

  • Lateral malleolar fracture with deltoid ligament damage

  • Fibula fracture at or proximal to the tibiotalar joint line (eg, Danis-Weber classification type C)

  • All bimalleolar fractures

  • All trimalleolar fractures

  • All intra-articular fractures

  • All open fractures

  • All pilon fractures

Consult a vascular surgeon when vascular flow to the ankle or foot is compromised. In a fracture with vascular compromise, angiography may be necessary.

Medical Care

Discharge instructions should include elevation of the affected leg, application of ice, and non-weight bearing on the injured joint.

Ice packs can be applied to areas of swelling for 10-15 minutes every 3-4 hours while awake for the first 24-48 hours. Ice works through splints.[21, 22]

Advise patients to refrain from bearing weight on the ankle until seen by orthopedist. Provide crutches and instructions on their proper use. Ensure proper use of the crutches before discharge from the ED.

All patients with ankle fractures should receive follow-up instructions for consultation with a specialist (eg orthopedist, podiatrist). Many fractures, with the exception of most unimalleolar fractures, will eventually require ORIF.

Patients with gait disorders or other reasons that caused the ankle fracture must be assessed for a safe discharge to home. The ankle fracture might have a low morbidity, but concomitant inability to attend to activities of daily living due to conditions, such as ataxia or peripheral neuropathy, may warrant mobilization of additional support services or admission.

Provide written and oral information on cast and/or splint care and ensure that the patient understands which symptoms warrant immediate physician notification and/or return to the ED.

With increased immobilization, patients are at higher risk for deep vein thrombosis (DVT).

Indications for transferring the patient with an ankle fracture include the patient's or consultant requests for a transfer and inability of the treating facility to sufficiently to treat the ankle fracture (eg, requirement for ORIF in facility without operating room). Provide adequate stabilization prior to the transport. Discuss the type of immobilization with the accepting physicians. It may be a simple "pillow" type splint or more complex sterile dressing and combination posterior and stirrup splint. Be sure to document the neurovascular status of the leg and foot prior to and following the immobilization.

Complications

Nonunion of the fracture site requires orthopedic referral for operative repair.

Malunion of the fracture site occurs more frequently than nonunion and potentially proceeds to degenerative changes of the joint. Chronic persistent symptoms such as pain, weakness, and instability of the ankle may develop. Refer such patients to an orthopedist for evaluation and possible surgical revision.

Traumatic arthritis complicates 20-40% of ankle fractures. Generally, the more severe the fracture, the greater the likelihood of posttraumatic arthritis; comminuted pilon fractures are most at risk. Older patients have an increased risk of arthritic complications.

Sudeck atrophy, a type of reflex sympathetic dystrophy (RSD), may precede ankle fractures. Clinical features include complex pain, muscle atrophy, cyanosis, and edema. The term Sudeck atrophy is reserved for RSD-like conditions accompanied by a characteristic radiographic appearance (ie, spotty rarefaction), as opposed to the ground-glass appearance seen with disuse atrophy of bone.

Osteochondral fractures of the talar surface can easily go unrecognized and if left untreated may result in chronic pain, locking, and swelling. If suspected, arrange appropriate orthopedic follow-up care.

In children, ankle fractures involving the growth plate may cause chronic deformity with disturbance of growth of the limb.

Prevention

Encourage the patient to undergo rehabilitation to regain strength of the ankle joint.

Orthotics and proper shoe gear may help prevent future injury.

 

Guidelines

Guidelines Summary

Ottawa Ankle Rules for Ankle Injury Radiography

An ankle x-ray series is only required if there is any pain in the malleolar zone and any of these findings[23] :

  • Bone tenderness at the posterior edge or tip of the lateral malleolus
  • Bone tenderness at the posterior edge or tip of the medial malleolus
  • Inability to take 4 complete steps both immediately and in the ED

A foot x-ray series is only required if there is any pain in the midfoot zone and any of these findings:

  • Bone tenderness at the base of the 5th metatarsal
  • Bone tenderness at the navicular
  • Inability to take 4 complete steps both immediately and in the ED

Apply the Ottawa Ankle Rules accurately:

  • Palpate the entire distal 6 cm of the fibula and tibia
  • Do not neglect the importance of medial malleolar tenderness
  • Do not use for patients under age 18 years

Clinical judgement should prevail over the rules in the following circumstances:

  • If the patient is intoxicated or uncooperative
  • If the patient has other distracting painful injuries
  • If the patient has diminished sensation in the legs
  • If the patient has gross swelling that prevents palpation of malleolar bone tenderness

Give written instructions and encourage follow-up in 5-7 days if pain and ability to walk are not better.

 

Medication

Medication Summary

Provide sufficient analgesia to patients sustaining an ankle fracture. A variety of medications can be used, ranging from oral acetaminophen to parenteral narcotics. For procedural sedation, agents include short-acting sedative-hypnotics and opiate analgesics, usually in combination. In addition, administer tetanus prophylaxis for open fractures.

Narcotic/analgesics

Class Summary

Pain control is essential to quality patient care as it ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Sedating properties of narcotics benefit patients who have sustained fractures.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

Used to achieve a desired anxiolytic and analgesic effect because easily titrated to desired level of pain control or sedation. Reversed by naloxone.

Fentanyl citrate (Duragesic, Sublimaze)

Good choice for immediate pain relief and conscious sedation because of its rapid onset and short duration (30-60 min). Easily titrated to desired level of pain control or sedation. Easily reversed by naloxone.

Anxiolytic/hypnotics

Class Summary

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow administration of a smaller analgesic dose to achieve the same effect.

Midazolam hydrochloride (Versed)

Short-acting benzodiazepine/sedative hypnotic used for its anxiolytic, amnestic, and sedating properties. Easily titrated and easily reversed with flumazenil.

Antidotes

Class Summary

In procedural sedation, a benzodiazepine antagonist may be needed to reverse the sedation and respiratory depression resulting from benzodiazepines and narcotics.

An opioid antagonist also can be used to reverse oversedation in a patient manifesting significant respiratory depression.

Flumazenil (Romazicon)

Selective antagonist of benzodiazepine receptor.

Naloxone (Narcan)

Prevents or reverses opioid effects including hypotension, respiratory depression, and sedation, possibly by displacing opiates from their receptor. Rapid onset of 1-2 min. Oversedation or respiratory depression should reverse rapidly.

Antibiotics

Class Summary

Therapy must cover all likely pathogens in the clinical setting.

Cefazolin (Ancef, Kefzol, Zolicef)

Cephalosporin that binds to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis, and inhibits bacterial replication. Primarily active against skin flora, including Staphylococcus aureus.

Total daily dosages are the same for IV and IM routes.

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. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.

Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Also useful in treatment of septicemia and skin structure infections. Used in conjunction with gentamicin for prophylaxis in patients with open fractures.

May need to adjust dose in patients with renal impairment.

Toxoids

Class Summary

These agents are used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

Used to induce active immunity against tetanus in selected patients; tetanus and diphtheria toxoids are immunizing agents of choice for most adults and children >7 y; administer booster doses throughout life to maintain tetanus immunity; 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 is midthigh laterally.

Immunoglobulins

Class Summary

Administer tetanus immune globulin to patients who may not have been immunized against Clostridium tetani products.

Tetanus immune globulin (TIG)

For passive immunization of persons with wounds that may be contaminated with tetanus spores.