Forearm Fracture Management in the ED Medication

Updated: Feb 04, 2022
  • Author: Toluwumi Jegede, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Medication

Medication Summary

Generally, use NSAIDs and analgesics to treat fractures. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures. According to a study involving 134 children treated for fracture in the ED, ibuprofen is just as effective as morphine for pain control. Children in the study received either 4 doses of normal-release morphine or 4 doses of ibuprofen every 6 hours, as needed, for 24 hours following discharge. No significant differences between groups were seen in pain scores after any of the 4 doses. Adverse effects of morphine included nausea, vomiting, and drowsiness. The percentage of patients in the morphine group experiencing adverse events was 56.1%, compared with 30.9% in the ibuprofen group (P< 0.01). [27, 28]

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Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

These drugs are used most commonly for relief of mild to moderately severe pain. Although effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the drug of choice (DOC) for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Selected as usual DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, inhibiting prostaglandin synthesis.

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small bodies, to older persons, and to those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe.

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, decreasing prostaglandin synthesis.

Flurbiprofen (Ansaid, Ocufen)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

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Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotics 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)

Used for prophylaxis in patients undergoing dental, oral, or respiratory tract procedures. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. This drug is given in place of amoxicillin in patients unable to take medication orally. It is also used along with gentamicin 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 penicillin-allergic patients undergoing GI or GU procedures. Dose may need to be adjusted for patients with renal impairment.

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Toxoid

Class Summary

This agent is 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 AOC for most adults and children >7 years. Booster doses needed to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. In children and adults, may be administered into deltoid or mid-lateral thigh muscles. In infants, preferred site of administration is mid-thigh laterally.

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Immunoglobulins

Class Summary

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (TIG)

Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.

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