›Pain control framework
›Acetaminophen oral 1000 mg
›Maximum 4000 mg per 24 hours
›Lower maximum in liver disease
›Ibuprofen oral 400 to 600 mg
›Every 6 to 8 hours as needed
›Avoid in significant renal disease GI bleed risk
›Naproxen oral 250 to 500 mg
›Every 12 hours as needed
›Avoid in pregnancy third trimester
›Oxycodone oral 5 mg
›Every 4 to 6 hours as needed for severe pain
›Short course with bowel regimen
›Ondansetron oral disintegrating 4 mg
›Every 8 hours as needed
›QT risk consideration
Reduction and immobilization
›Reduction pathway
›If fracture dislocation or malalignment, initiate reduction
›Inline traction and reversal of deforming force
›Skin tenting relief goal
›Immediate post reduction pulses and sensation check
›Post reduction imaging
›Repeat ankle radiographs
›Mortise view alignment check
›Immobilization choices
›Posterior short leg splint
›Neutral ankle position
›Padding for swelling
›Crutch training before discharge
›Posterior splint plus stirrup
›Unstable malleolar fractures
›Syndesmotic injury suspicion
›Avoid circumferential cast in first 48 to 72 hours
Procedural sedation and regional options
›Analgesia sedation options
›Intra articular hematoma block
›Lidocaine 1 percent 10 to 20 mL
›Aspiration confirmation of intra articular placement
›Avoid if open fracture or infection concern
›Ketamine IV 1 mg per kg
›Additional 0.5 mg per kg as needed
›Emergence reaction mitigation plan
›Class IIa for ED procedural sedation in appropriate monitoring settings
›Propofol IV 0.5 to 1 mg per kg initial
›Additional 0.25 to 0.5 mg per kg as needed
›Apnea hypotension risk monitoring
›Class IIa for ED procedural sedation with trained staff
›Fentanyl IV 0.5 to 1 microgram per kg
›Titrate to effect
›Respiratory depression monitoring
›Naloxone availability
Antibiotics tetanus and wound care
›Open fracture bundle
›Cefazolin IV 2 g
›Every 8 hours
›Increase to 3 g if very high body mass
›Class I for early antibiotic administration in open fractures
›If severe cephalosporin allergy
›Clindamycin IV 900 mg
›Every 8 hours
›Add gram negative coverage for severe contamination per local protocol
›Irrigation and sterile dressing
›Remove gross debris
›Moist sterile dressing
›Splint after dressing
›Tetanus prophylaxis
›If unknown or incomplete immunization and dirty wound, tetanus vaccine plus immune globulin
›If immunized and last dose over 5 years for dirty wound, booster
Operative indications and stability
›Surgical consideration triggers
›Unstable ankle mortise
›Bimalleolar fracture
›Trimalleolar fracture
›Medial clear space widening on mortise view
›Syndesmotic instability
›Widened tibiofibular clear space
›Proximal fibula fracture pattern
›Posterior malleolus large fragment
›Articular incongruity
›Posterior instability
›Open fracture
›Irrigation debridement and fixation planning
›Compartment syndrome vigilance