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AUTHOR INFORMATION
| Section 1 of 11   |
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| Author: Daniel Corboy, MD, Clinical Instructor, Department of Emergency Medicine, Harvard University Medical School, Massachusetts General Hospital Coauthor(s): D Daniel Rotenberg, MD, Consulting Surgeon, Department of Orthopedic Surgery, Western Orthopedics and Sports Medicine |
| Daniel Corboy, MD, is a member of the following medical societies:
Massachusetts Medical Society |
| Editor(s): Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine;
Tom Scaletta, MD, Assistant Professor, Department of Emergency Medicine, Rush Medical College;
John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School;
and Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine |
Disclosure
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INTRODUCTION
| Section 2 of 11   |
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Background: Elbow fractures are encountered commonly in the ED. Injury patterns for children and adults are quite different. Emergency physicians must recognize whether fractures require admission, immediate orthopedic evaluation, or less urgent referral.
Pathophysiology: Direct trauma or a fall onto an outstretched hand is responsible for most elbow fractures. Triceps muscle insertion on the olecranon often causes its displacement following fracture. Elbow joints are composed of 3 distinct articulations: radiocapitellar, ulnatrochlear, and proximal radioulnar, all contained in 1 synovial-lined capsule. This capsule typically encases hemarthrosis following injury.
The brachial artery is the most commonly injured artery. This is especially common in supracondylar fractures.
The median nerve is the most commonly injured nerve. This injury often is due to displaced supracondylar humerus fracture.
Age:
- Fracture patterns vary markedly among different age groups.
- Supracondylar humerus fractures are most common in children aged 4-10 years because of this age group's relative strength of surrounding ligaments in comparison to bone.
- Injuries to proximal radius often manifest as radial neck fractures in children and radial head fractures in adults.
- Intraarticular condyle fractures are seen in children and adults.
History: - Mechanism of injury for most elbow fractures is direct elbow trauma or a fall onto an outstretched hand. Patients may experience the following:
- Decreased range of motion
Physical: - Patient is unable to fully extend elbow, and pain is present with pronation/supination of the forearm.
- Edema and ecchymosis near the elbow may be evident.
- Perform careful shoulder and wrist examinations with all elbow injuries.
- Radial head fracture is characterized by point tenderness at the radial head (located along lateral aspect of elbow) and pain with pronation/supination.
- Perform and document a careful vascular examination, as the brachial artery may be disrupted.
- Perform and document a careful neurologic exam, as nerves (most commonly the median nerve or one of its branches, the anterior interosseus nerve) may be injured.
- Patient demonstrates an inability to extend elbow actively, along with point tenderness at the olecranon.
- Perform and document a careful neurologic exam, as nerves (most commonly the ulnar nerve) may be injured.
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DIFFERENTIALS
| Section 4 of 11 |
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Dislocations, Elbow
Fractures, Forearm
Fractures, Humerus
Pediatrics, Nursemaid Elbow
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Imaging Studies:
- Anteroposterior (AP), lateral, and oblique radiographs of the elbow adequately visualize most elbow fractures.
- On all views, the center of the radial head should align with the center of the capitellum.
- Misalignment of the radial head and capitellum indicates a subluxed or dislocated radial head.
- Lateral elbow radiograph best demonstrates a displaced radial head fracture.
- AP view may not always reveal fracture.
- Posterior fat pad is a soft-tissue finding that is appreciated on the lateral radiograph and appears as a radiolucency in the posterior aspect of the distal humerus. Its presence is always abnormal and usually represents hemarthrosis displacing a posterior fat pad, signifying an occult fracture. Anteriorly, a fat pad adjacent to the distal humerus is usually a normal finding. In radial head fractures, however, hemarthrosis can displace the fat pad anteriorly, resulting in the sail sign.
- Radiocapitellar view may be helpful in identifying subtle fractures. To perform this view, position for a lateral view of the elbow and angle the radiograph tube 45 degrees toward the shoulder.
- Lateral radiograph demonstrates a displaced intraarticular fracture.
- Use AP view to identify associated fracture or dislocation.
- Supracondylar humerus fracture (Image 3)
- Base treatment decisions upon angulation and displacement seen in AP and lateral views.
- On lateral view, condyles lie anterior to the shaft of the humerus. Occasionally, a greenstick fracture may be appreciated only by change in condylar position.
Procedures:
- In general, an orthopedic consultant best handles decisions regarding reduction of significantly angulated and displaced fractures.
- If neurovascular structures are compromised, the emergency physician may need to apply forearm traction to reestablish distal pulses.
- If pulse is not restored with traction, emergent operative intervention for brachial artery exploration or fasciotomy is indicated.
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TREATMENT
| Section 6 of 11 |
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Emergency Department Care: - Provide adequate analgesia to achieve patient comfort in ED.
- For nondisplaced fractures, a sling is all that is necessary.
- For displaced fractures, closed reduction rarely is required or possible.
- Patients can be placed in a posterior long arm splint with the elbow in 90° of flexion and forearm in full supination, then given a sling for comfort.
- Patients can be placed in a well padded, long-arm posterior splint with the elbow in 70° of flexion and forearm neutral with respect to pronation/supination.
- Refer these patients to an orthopedic surgeon.
- Adult patients usually require surgical intervention.
- In children, nondisplaced, nonangulated fractures can be splinted (elbow in 90° of flexion); angulated fractures require reduction and splinting; and displaced fractures require reduction and percutaneous pinning on an urgent basis within 12-24 hours.
Consultations: - Bleeding around the elbow raises suspicion of an open fracture or open joint and requires urgent orthopedic consultation.
- Supracondylar fracture: A displaced supracondylar fracture requires urgent orthopedic consultation because of significant risk of neurovascular injury and compromise. Admit patient for serial neurovascular checks.
- Olecranon fracture: Loss of active extension or intraarticular displacement of greater than 1 mm are indications for surgical treatment.
- Radial head fracture
- Occult or small radial head fractures are treated symptomatically with early range of motion exercises.
- For displaced or comminuted fractures mechanically blocking joint motion, surgical intervention may be necessary. Refer these patients to an orthopedic surgeon.
- Radial neck fracture: Angulation greater than 15° often requires closed reduction.
- Condylar fracture: Displaced fractures of the trochlea or capitellum require surgical intervention.
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MEDICATION
| Section 7 of 11 |
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Drugs used to treat fractures are generally NSAIDs, analgesics, and anxiolytics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.
Drug Category: 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. Drug Name
| 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 Dose | 200-400 mg PO q4-6h prn; not to exceed 3.2 g/d |
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| Pediatric Dose | 6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding |
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| Interactions | 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 |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy |
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Drug Name
| Ketoprofen (Oruvail, Orudis, Actron) -- Relieves mild to moderately severe pain and inflammation.
Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease.
Doses higher than 75 mg do not increase therapeutic effects.| Adult Dose | 25-50 mg PO q6-8h prn; not to exceed 300 mg/d |
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| Pediatric Dose | 3 months to 14 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults| Contraindications | Documented hypersensitivity |
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| Interactions | 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 |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy |
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Drug Name
| 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. |
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| Adult Dose | 500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d |
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| Pediatric Dose | <2 years: Not established
>2 years: 5-7 mg/kg/dose PO q8-12h prn| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
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| Interactions | 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 |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Category D in third trimester of pregnancy; 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 |
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Drug Name
| Flurbiprofen (Ansaid) -- Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis. |
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| Adult Dose | 200-300 mg/d PO divided bid/qid |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity |
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| Interactions | 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 |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Category D in third trimester of pregnancy; 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 |
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Drug Category: 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.Drug Name
| Acetaminophen (Tylenol, Panadol, aspirin-free Anacin) -- DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants. |
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| Adult Dose | 325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d |
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| Pediatric Dose | <12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg q4h; not to exceed 5 doses/d| Contraindications | Documented hypersensitivity; known G-6-P deficiency |
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| Interactions | Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose |
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Drug Name
| Hydrocodone bitartrate and acetaminophen (Vicodin ES) -- Drug combination indicated for relief of moderately severe to severe pain. |
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| Adult Dose | 1-2 tab/cap PO q4-6h prn |
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| Pediatric Dose | <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| Contraindications | Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure |
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| Interactions | Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Tablets contain metabisulfite which may cause hypersensitivity; caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction |
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Drug Name
| Oxycodone and acetaminophen (Percocet) -- Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients. |
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| Adult Dose | 1-2 tab/cap PO q4-6h prn |
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| Pediatric Dose | 0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Duration of action may increase in the elderly; 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 |
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Drug Name
| Oxycodone and aspirin (Percodan) -- Drug combination indicated for relief of moderately severe to severe pain. |
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| Adult Dose | 1-2 tab/cap PO q4-6h prn |
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| Pediatric Dose | 0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone |
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| Contraindications | Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Due to association of aspirin with Reye syndrome do not use in children (<16 y) who have flu| Interactions | Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity; may potentiate anticoagulant effects of warfarin |
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| Pregnancy |
D - Unsafe in pregnancy
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| Precautions | Duration of action may increase in the elderly; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis |
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Drug Category: Anxiolytics -- Patients with painful injuries usually experience significant anxiety. Anxiolytics allow a smaller analgesic dose to achieve the same effect.Drug Name
| 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 Dose | Initial dose: 2 mg total or 0.044 mg/kg IV, whichever is smaller |
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| Pediatric Dose | 0.05 - 0.1 mg/kg IV slowly q2-5min; may repeat dose of 0.05 mg/kg IV slowly |
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| Contraindications | Documented hypersensitivity; preexisting CNS depression; hypotension; and narrow-angle glaucoma |
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| Interactions | Alcohol, phenothiazines, barbiturates, and MAOIs increase CNS toxicity |
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| Pregnancy |
D - Unsafe in pregnancy
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| Precautions | Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease |
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Drug Category: Antibiotics -- These agents are given as prophylaxis to patients with open fractures.Drug Name
| 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 Dose | 1.5 mg/kg/dose IV q8-24h; not to exceed 80 mg; may need dosage adjustment in patients diagnosed with renal impairment |
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| Pediatric Dose | <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| Contraindications | Documented hypersensitivity; non–dialysis-dependent renal insufficiency |
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| Interactions | 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) |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| 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 |
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Drug Name
| Ampicillin (Omnipen, Marcillin) -- Used along with gentamicin for prophylaxis in patients with open fractures. |
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| Adult Dose | 1-2 g IV/IM q6h |
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| Pediatric Dose | 100-200 mg/kg/day IV/IM divided q6h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction |
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Drug Name
| 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 with open fractures. Dosing interval based on renal function. |
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| Adult Dose | 10 mg/kg/dose IV q8-24h; adjust interval on basis of renal function
Usual dose: 1000 mg IV q12h; infuse over 1 h| Pediatric Dose | 10 mg/kg/dose IV q8h; infuse over 1 h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Anesthetic agents may cause erythema, histamine-like flushing, and anaphylactic reactions; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; nondepolarizing muscle relaxants may enhance effects in neuromuscular blockade |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given over 2 h or by PO or IP route; red man syndrome is not an allergic reaction |
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Drug Name
| Ceftriaxone (Rocephin) -- Third-generation cephalosporin that has broad-spectrum efficacy against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.
By binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial replication.| Adult Dose | 1-2 g IV qd; not to exceed 4 g/d |
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| Pediatric Dose | Neonates >7 days: 25-50 mg/kg/d IV; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV qd; not to exceed 2 g/d| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid may increase levels; ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin |
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Drug Category: Toxoid -- This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.Drug Name
| 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 Dose | 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 Dose | Administer as in adults |
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| Contraindications | 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 |
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| Interactions | 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) |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| 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 |
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Drug Category: Immunoglobulins -- Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.Drug Name
| Tetanus immune globulins (Hyper-Tet) -- For passive immunization of any person with a wound that may be contaminated with tetanus spores. |
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| Adult Dose | For prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid
For clinical tetanus: 3,000-10,000 U IM| Pediatric Dose | For prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
For clinical tetanus: 3,000-10,000 U IM| Contraindications | Since 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 |
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| Interactions | None reported |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| 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 |
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FOLLOW-UP
| Section 8 of 11 |
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Further Inpatient Care:
- Open fractures require extensive irrigation. Administer appropriate prophylactic antibiotics, such as cefazolin sodium 1 g IV and gentamicin.
- Supracondylar fractures: In children, displaced fractures require surgical intervention and continual monitoring of neurovascular status.
Further Outpatient Care:
- For uncomplicated fractures, begin range of motion exercises within 3-7 days to reduce risk of permanent loss of motion from elbow joint contracture.
- Intraarticular fractures, which may require radial head excision or fixation, should be seen by an orthopedist within 1 week for definitive management.
- Olecranon fracture: Nonoperative fractures (minimally displaced with an intact extensor mechanism) can be treated with a splint and range of motion exercises within a few weeks.
- Refer patients with nondisplaced fractures to an orthopedist within 24 hours to evaluate and recheck neurovascular status.
- Upon dissipation of edema, apply a long arm cast that holds elbow in 90° of flexion for approximately 6 weeks.
In/Out Patient Meds:
- As with all fractures, address adequate outpatient analgesia, especially during first few days. Acetaminophen, with codeine or hydrocodone, may be appropriate treatment.
Complications:
- Nondisplaced fractures that are immobilized for prolonged periods of time may have permanently decreased range of motion.
- Comminuted radial head fractures associated with undiagnosed distal radial-ulnar joint injuries can lead to permanent wrist injuries and loss of pronation/supination motion.
- Supracondylar humerus fracture
- Volkmann ischemia: This is a form of compartment syndrome that can lead to muscle ischemia and permanent muscle contracture, particularly occurring in children. Symptoms suggestive of this complication include pain with passive extension of fingers, refusal to open hand, and forearm tenderness.
- Median nerve injury: Displaced supracondylar humerus fractures may lead to median nerve dysfunction. Rarely does this result in complete nerve transection, and full return of function is common.
- Malunion: Angulated or displaced fractures that remain unreduced lead to functional and cosmetic deformities.
- Olecranon fracture: An ulnar nerve injury, although rare, may be associated with a displaced olecranon fracture.
Prognosis:
- Radial head fracture - Usually no functional loss with nonoperative treatment
- Supracondylar humerus fracture
- Children: Undisplaced fractures and properly managed displaced/angulated fractures result in no long-term functional deficits.
- Adults: Usually range of motion decreases somewhat but without functional deficit.
- This fracture may result in loss of full extension but usually restores strength.
- Olecranon fracture can be associated with posttraumatic arthritis of elbow.
- Most operative and nonoperative cases of olecranon fracture have a good outcome with no long-term deficits.
Patient Education:
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MISCELLANEOUS
| Section 9 of 11 |
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Medical/Legal Pitfalls:
- Failure to document a neurovascular exam in a child with a supracondylar fracture
- Failure to reexamine and document neurovascular exam following application of a splint. Elbow flexion greater than 90° may obliterate pulse or compromise neurologic function.
- Failure to pad olecranon when splinting an olecranon fracture may lead to skin breakdown and iatrogenic open fracture.
- Failure to maintain prolonged immobilization of radial head fractures leads to permanently decreased range of motion.
- Failure to recognize a radial head dislocation associated with a fracture of the proximal ulna (Monteggia fracture or dislocation)
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PICTURES
| Section 10 of 11 |
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BIBLIOGRAPHY
| Section 11 of 11 |
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Karlsson MK, Hasserius R, Karlsson C, et al: Fractures of the olecranon: a 15- to 25-year followup of 73 patients. Clin Orthop 2002 Oct; 205-12[Medline].
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Rosen P: Emergency Medicine. 2nd ed. Mosby-Year Book, Incorporated; 1988: 749-755.
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Steinberg G, Adkins C, Baran D: Orthopaedics in Primary Care. 2nd ed. Williams & Wilkins; 1992: 62-85.
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Tintinalli J, Krome R, Ruiz E, eds: Emergency Medicine. 4th ed. McGraw Hill Text; 1996: 897-898.
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