Medication Summary
Control discomfort with nonsteroidal anti-inflammatory drugs (NSAIDs), and if pain continues, add a narcotic analgesic. The latter often have a sedative effect, which is beneficial for patients who have sustained trauma. Acetaminophen is the drug of choice (DOC) for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, as well as in those who have upper gastrointestinal (GI) disease or are taking oral anticoagulants.
Prophylactic intravenous antibiotics that cover typical skin flora (eg, cefazolin sodium) are necessary with open fractures. Tetanus immunization also may be indicated.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Class Summary
NSAIDs are a drug of choice for pain resulting from injuries. In cases of severe pain, opioid analgesic agents may be prescribed.
Ibuprofen (Motrin, Advil, Neoprofen, Ultraprin)
Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. It is used to provide relief of cervical myofascial pain.
Indomethacin (Indocin)
Indomethacin is thought to be the most effective NSAID for the treatment of ankylosing spondylitis, although no scientific evidence supports this claim. It is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.
Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)
Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.
Diclofenac (Voltaren, Cataflam XR, Zipsor, Cambia)
Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases the formation of prostaglandin precursors.
Ketoprofen
Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.
Celecoxib (Celebrex)
Celecoxib primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient. It is extensively metabolized in the liver primarily via cytochrome P450 2C9.
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will most benefit from COX-2 inhibitors.
Analgesics
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.
Acetaminophen and codeine (Tylenol #3)
This combination is indicated for the treatment of mild to moderate pain.
Acetaminophen (Tylenol, Aspirin Free Anacin, Cetafen, APAP 500, Mapap Extra Strength)
Acetaminophen is the drug of choice for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, as well as in those with upper GI disease or those who are taking oral anticoagulants.
Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lortab, Lorcet Plus, Norco, Maxidone)
This agent is indicated for the relief of moderately severe to severe pain.
Oxycodone and acetaminophen (Percocet, Primlev, Roxicet, Endocet)
The oxycodone/acetaminophen combination is indicated for the relief of moderately severe to severe pain.
Antibiotics
Class Summary
Therapy must cover all likely pathogens in the clinical setting.
Cefazolin
This agent is a first-generation semisynthetic cephalosporin that, by binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial replication. It is primarily active against skin flora, including Staphylococcus aureus.
Gentamicin
Gentamicin is an aminoglycoside antibiotic used for gram-negative bacterial coverage. It is commonly used in combination with an agent against gram-positive organisms and one that covers anaerobes. The drug is used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.
Dosing regimens are numerous and are adjusted based on creatinine clearance (CrCl) and changes in volume of distribution. Gentamicin may be given intravenously or intramuscularly.
Ampicillin
Ampicillin is used along with gentamicin for prophylaxis in patients with open fractures. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Vancomycin
This potent antibiotic is directed against gram-positive organisms and is active against enterococcal species. It is useful in septicemia and skin structure infections. Vancomycin is used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients with open fractures.
Dose adjustment may be necessary in patients with renal impairment.
Vaccines, Inactivated Bacterial
Class Summary
Tetanus toxoid is used for immunization against tetanus. A booster injection in previously immunized individuals is recommended to prevent the disease.
Tetanus toxoid
This agent induces active immunity against tetanus. Immunizing agents of choice for most adults and children older than 7 years are the tetanus and diphtheria toxoids. Booster doses are administered to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen ̶ containing product.
In children and adults, tetanus toxoid may be administered into the deltoid or midlateral thigh muscles. In infants, the preferred site of administration is the midthigh laterally.
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A posterior view demonstrating a closed clavicle fracture tenting the skin (arrow), which can potentially lead to an open fracture.
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Comparison of both clavicles, with the left tenting the skin (wide arrow).
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Close-up view of clavicle tenting the skin (arrow).
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Comminuted fracture in a hockey player. Note the medial fragment tenting the skin.
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Additional view of fracture displacement and comminution in a hockey player. The sternocleidomastoid is the deforming force of the medial fragment.
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Radiographs after open reduction and internal fixation of a comminuted fracture in a hockey player.
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Anteroposterior view of middle third clavicle fracture illustrating a relatively typical fracture pattern.
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Anteroposterior view of distal clavicle fracture, type II, showing wide displacement.
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The displacing forces on a midshaft clavicle fracture.
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The displacing forces on a distal clavicle fracture.
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Type I fracture of the distal clavicle (group II). The intact ligaments hold the fragments in place.
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A type II distal clavicle fracture. In type IIA, both conoid and trapezoid ligaments are on the distal segment, while the proximal segment, without ligamentous attachments, is displaced.
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A type IIB fracture of the distal clavicle. The conoid ligament is ruptured, while the trapezoid ligament remains attached to the distal segment. The proximal fragment is displaced.
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Anatomy of the clavicle indicating potential fracture sites.
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Nondisplaced middle clavicle fracture.
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Displaced fracture of middle clavicle.
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Displaced middle clavicle fracture.
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Clavicle fracture with rib fractures. Remember to look for associated injuries.
