Medication Summary

Parenteral analgesia is strongly recommended. A muscle relaxant also may be necessary. Administer antibiotics to cover skin flora (ie, cefazolin sodium) and tetanus immunization, as necessary, in open fractures.

Class Summary

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 who have sustained fractures.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

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DOC for narcotic analgesia due to its reliable and predictable effects, safety, and ease of reversibility with naloxone.

Morphine sulfate administered IV may be dosed in a number of ways and commonly is titrated until desired effect attained.

Fentanyl citrate (Duragesic, Sublimaze)

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More potent narcotic analgesic than morphine sulfate with much shorter half-life. DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia (premedication, induction, maintenance), and in immediate postoperative period.

With short duration (30-60 min) that is easy to titrate, excellent choice for pain management and sedation. Easily and quickly reversed by naloxone.

After initial dose, do not titrate subsequent doses more frequently than q3h or q6h. When using transdermal dosage form, pain is controlled in most patients with 72-h dosing intervals. However, a small number of patients require dosing intervals of 48 h.

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

Cefazolin (Ancef, Kefzol, Zolicef)

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First-generation, semisynthetic cephalosporin that acts by binding to 1 or more penicillin-binding proteins to arrest bacterial cell wall synthesis and inhibit bacterial replication. Primarily active against skin flora, including Staphylococcus aureus. Typically use alone for skin and skin-structure coverage.

Total daily dosages are same for IV/IM routes.

Gentamicin (Gentacidin, Garamycin)

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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.

Ampicillin (Omnipen, Marcillin)

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Used along with gentamicin for prophylaxis in patients with open fractures. Interferes with bacterial cell wall synthesis during active multiplication, causing bactericidal activity against susceptible organisms. Given in place of amoxicillin in patients unable to take medication orally.

Vancomycin (Vancocin)

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Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Also useful in treatment of septicemia and skin-structure infections.

Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients with open fractures.

May need to adjust dose in patients with renal impairment.

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Media Gallery

Shenton line and angular anatomy of the femur.
Femoral head fractures. Top diagram is a single-fragment femoral head fracture. Bottom diagram is a comminuted femoral head fracture.
Femoral neck fractures. Top diagram is a nondisplaced, or incomplete, femoral neck fracture. Bottom diagram is an impacted femoral neck fracture.
Partially displaced femoral neck fracture.
Completely displaced femoral neck fracture.
Trochanteric fractures. Top diagram is a nondisplaced trochanteric fracture. Bottom diagram is a displaced trochanteric fracture.
Intertrochanteric fractures. Top diagram is a single fracture line intertrochanteric fracture. Bottom diagram is a displaced, or multiple fracture line, intertrochanteric fracture.