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Approach to the Critical Patient
Initial priorities
Initial priorities
Trauma activation criteria
High-energy mechanism
SBP < 90 mmHg
Altered mental status
Suspected open fracture
Suspected vascular injury
Airway and breathing threats
Hypoxia
Aspiration risk
Circulation threats
Hemorrhagic shock risk from femoral fracture
Estimated blood loss up to 1.5 L in closed femoral shaft fracture
Higher risk with open fracture
Higher risk with polytrauma
Analgesia and immobilization first-pass bundle
Early regional anesthesia option
Early splint or traction strategy
Hemorrhage and shock
Hemorrhage and shock
Hemodynamic targets
SBP ≥ 90 mmHg
MAP ≥ 65 mmHg
Mental status improvement target
Urine output ≥ 0.5 mL/kg/hour
Hemorrhage source control
Femur immobilization to reduce ongoing bleeding
Thomas splint option
Traction splint option with contraindication screen
Concomitant hemorrhage search
Pelvis
Abdomen
Chest
Resuscitation strategy
Large-bore IV access
Massive transfusion protocol trigger
Persistent hypotension despite initial fluids
Ongoing bleeding concern
Shock index > 1
Balanced blood product strategy
RBC
Plasma
Platelets
Antifibrinolytic option
If major trauma with hemorrhagic shock and within 3 hours, initiate TXA protocol
TXA 1 g IV over 10 minutes
Then TXA 1 g IV over 8 hours
Avoid if > 3 hours since injury
Limb threat screening
Limb threat screening
Neurovascular compromise triggers
Absent distal pulses
Immediate reduction of gross deformity if tensioned
Immediate vascular surgery consult
CT angiography lower extremity when stable
Expanding hematoma
Immediate vascular surgery consult
Hard signs of vascular injury
Pulsatile bleeding
Bruit or thrill
Distal ischemia
Compartment syndrome triggers
Pain out of proportion
Pain with passive stretch
Paresthesia
Tense compartments
If high concern, emergent orthopedics
Open fracture triggers
Antibiotics within 1 hour
Tetanus prophylaxis pathway
Orthoplastic or trauma center transfer if required
History
Mechanism and symptom pattern
Mechanism and symptom pattern
Mechanism
High-energy MVC
Fall from height
Low-energy fall in older adult
Timing
Time of injury
Time since last oral intake
Pain characteristics
Hip pain
Thigh pain
Knee pain
Function baseline
Pre-injury ambulation
Baseline ADLs
Assistive devices
Risk modifiers
Risk modifiers
Bleeding risk
Anticoagulants
Antiplatelets
Bleeding disorder
Bone health
Osteoporosis history
Prior fragility fractures
Long-term glucocorticoids
Infection risk
Diabetes
Immunosuppression
Associated injury clues
Head injury symptoms
Chest pain or dyspnea
Abdominal pain
Pelvic pain
Red flags and special contexts
Red flags and special contexts
Pathologic fracture concern
Known malignancy
Night pain
Minimal trauma
Non-accidental trauma concern
Inconsistent story
Delay in presentation
Pregnancy status when applicable
Gestational age estimate
Abdominal pain
Vaginal bleeding
Physical Exam
Primary survey focused exam
Primary survey focused exam
Vital signs and shock markers
Tachycardia
Hypotension
Cool clammy skin
Delayed capillary refill
Mental status
GCS trend
Agitation
Hemorrhage check
External bleeding
Pelvic instability concern
Limb and joint exam
Limb and joint exam
Inspection
Shortened externally rotated leg
Proximal femur fracture pattern suspicion
Thigh deformity
Femoral shaft fracture suspicion
Knee swelling
Distal femur fracture suspicion
Open wound
Contamination assessment
Palpation and stability
Hip tenderness
Thigh tenderness
Knee tenderness
Crepitus
Neurovascular exam
DP pulse
Asymmetry vs contralateral
PT pulse
Asymmetry vs contralateral
Capillary refill time
Motor function foot and ankle
Sensation dorsum and plantar foot
Compartment syndrome screen
Pain with passive stretch
Tense compartments
Paresthesia
Pitfalls
Pitfalls
Missed associated injuries
Pelvic ring injury
Knee ligament injury
Tibial plateau fracture
Hip dislocation
False reassurance from single normal pulse check
Serial neurovascular exams
Doppler pulses if equivocal
Anchoring on hip fracture in older adult
Consider pelvic fracture
Consider femoral shaft or distal femur fracture
Differential Diagnosis
Life-threatening and limb-threatening
Life-threatening and limb-threatening
Hemorrhagic shock from long bone fracture
Femoral shaft fracture bleeding
Vascular injury
Femoral artery injury
Popliteal artery injury with distal femur or knee dislocation
Compartment syndrome thigh
Post-traumatic
Fat embolism syndrome
Hypoxemia
Neurologic changes
Petechiae
Mimics and associated injuries
Mimics and associated injuries
Hip dislocation
Posterior dislocation
Pelvic ring fracture
Unstable pelvis
Knee dislocation
Multiligament injury
Tibial plateau fracture
Knee effusion
Septic arthritis hip
Fever
Elevated inflammatory markers
Acute limb ischemia non-traumatic
Embolic event
Coding alignment
Coding alignment
ICD-10 femoral neck fracture S72.0
ICD-10 pertrochanteric fracture S72.1
ICD-10 subtrochanteric fracture S72.2
ICD-10 femoral shaft fracture S72.3
ICD-10 distal femur fracture S72.4
ICD-10 multiple femur fractures S72.7
SNOMED CT femur fracture concept alignment
SNOMED CT hip fracture concept alignment
Laboratory Tests
Hemorrhage and resuscitation labs
Hemorrhage and resuscitation labs
CBC for bleeding concern
Hemoglobin baseline
Platelet count baseline
Group and screen
Crossmatch if shock or operative pathway
Coagulation panel if bleeding or anticoagulant use
INR
aPTT
Fibrinogen if massive hemorrhage concern
Low fibrinogen predictor of severe hemorrhage
Lactate for shock physiology
Trend response to resuscitation
Venous blood gas when indicated
pH
pCO2 mmHg
Base deficit
Pre-op and medical optimization labs
Pre-op and medical optimization labs
Electrolytes and renal function
Sodium mmol/L
Potassium mmol/L
Creatinine
Glucose mmol/L
Hypoglycemia or hyperglycemia correction planning
CK if crush injury or prolonged down time
Rhabdomyolysis risk
Infection and open fracture adjuncts
Infection and open fracture adjuncts
Wound culture
Not routine before antibiotics
Consider in gross contamination with delayed presentation
CRP and WBC trend
Baseline for post-op interpretation
Diagnostic Tests
Scoring Systems
Scoring systems
Gustilo Anderson open fracture classification
Type I clean wound < 1 cm
Type II wound 1 to 10 cm without extensive soft tissue damage
Type III high-energy with extensive soft tissue damage
Type IIIA adequate soft tissue coverage
Type IIIB periosteal stripping with bone exposure
Type IIIC associated arterial injury requiring repair
AO OTA femur fracture classification
Proximal femur
Diaphyseal femur
Distal femur
Garden classification femoral neck fractures
Type I incomplete or valgus impacted
Type II complete nondisplaced
Type III complete displaced partial
Type IV complete displaced full
Mangled Extremity Severity Score
Vascular status component
Ischemia time component
Shock component
Age component
Shock index
HR divided by SBP
> 1 higher risk of severe hemorrhage
MRI
MRI
Indications
Occult femoral neck fracture with negative X-ray and persistent pain
Stress fracture suspicion
Performance
High sensitivity for occult hip fracture
High specificity for occult hip fracture
Timing considerations
Expedite when diagnosis changes weight-bearing and operative pathway
Contraindications
Non-MRI compatible implants
Unstable patient physiology
CT
CT
Indications
Complex proximal femur fracture pattern for operative planning
Distal femur intra-articular extension assessment
Polytrauma whole-body CT pathway
Suspected femoral neck fracture with equivocal X-ray when MRI not available
CT angiography lower extremity
Absent distal pulses
Hard signs pathway
Vascular surgery consult before imaging if unstable limb
ABI < 0.9 after reduction or immobilization
CTA trigger
Pitfalls
Contrast nephropathy risk in shock
False reassurance with intermittent vasospasm
Ultrasound
Ultrasound
eFAST in polytrauma
Pericardial effusion
Free intraperitoneal fluid
Pneumothorax
Hemothorax
Vascular Doppler adjunct
DP signal presence
PT signal presence
Serial comparison
Nerve block guidance
Femoral nerve block
Fascia iliaca compartment block
Limitations
Operator dependence
Deep vessel visualization limits in obesity
Disposition
Level of care and consults
Level of care and consults
Orthopedics consult
All suspected femur fractures
Emergent for open fracture
Emergent for vascular compromise
Trauma surgery consult
Polytrauma
Shock physiology
Vascular surgery consult
Hard signs vascular injury
CTA positive findings
ICU criteria
Persistent hemodynamic instability
Ongoing transfusion needs
Significant comorbid respiratory failure
Admission and transfer criteria
Admission and transfer criteria
Admission criteria
Femoral neck fracture
Intertrochanteric fracture
Subtrochanteric fracture
Femoral shaft fracture
Distal femur fracture
Transfer criteria
Need for orthoplastic coverage for severe open fracture
Need for vascular repair capability
Lack of definitive fixation capability
Time-sensitive priorities
Early surgery pathway for hip fractures when medically optimized
Open fracture antibiotics and debridement pathway
Treatment
Analgesia and sedation
Analgesia and sedation
Multimodal analgesia strategy
Acetaminophen PO 1000 mg
Maximum 4000 mg per 24 hours
Lower maximum with liver disease
Ibuprofen PO 400 mg
Avoid in renal failure
Avoid in active bleeding
Ketorolac IV 15 mg
Avoid in renal failure
Avoid in anticoagulated bleeding concern
Opioids for severe pain
Fentanyl IV 25 mcg
Repeat every 5 minutes for pain and respiratory status
Typical total 50 to 200 mcg
Hold for respiratory depression
Morphine IV 2 mg
Repeat every 5 to 10 minutes for pain
Typical total 0.05 to 0.1 mg/kg
Avoid in hemodynamic instability
Regional anesthesia
Fascia iliaca compartment block
Ropivacaine 0.2% 30 mL
Maximum local anesthetic dose by weight
Local anesthetic systemic toxicity precautions
Femoral nerve block
Bupivacaine 0.25% 20 mL
Maximum local anesthetic dose by weight
Avoid intravascular injection
Procedural sedation when required
Ketamine IV 0.5 mg/kg
Additional 0.25 mg/kg every 5 minutes for effect
Monitor airway and ventilation
Emergence reaction precautions
Immobilization and reduction
Immobilization and reduction
Immediate immobilization options
Long leg splint for distal femur fracture
Knee immobilizer adjunct
Hip stabilization adjunct
Traction splint for suspected midshaft femur fracture
Contraindication screen
Suspected distal femur fracture
Suspected knee dislocation
Ipsilateral tibia or ankle fracture
Pelvic fracture concern
Thomas splint option for transport
Improved pain control
Reduced motion
Gross deformity realignment if neurovascular compromise
If absent pulses, gentle longitudinal traction and realignment
Recheck pulses after realignment
Recheck sensation after realignment
Open fracture bundle
Open fracture bundle
Wound handling
Saline-soaked dressing with occlusive cover
Avoid repeated wound exploration
Avoid prehospital irrigation of long bone open fractures
Antibiotics timing
If open fracture, initiate IV antibiotics within 1 hour
Infection risk increases with delay beyond 1 hour
Antibiotic selection framework
Gustilo type I or II coverage
Cefazolin IV 2 g
Repeat every 8 hours
Weight-based higher dose option
Gustilo type III coverage
Cefazolin IV 2 g
Repeat every 8 hours
Plus gram-negative coverage
Gentamicin IV 5 mg/kg
Farm or fecal contamination coverage
Add anaerobic coverage
Penicillin G IV 4 million units
Repeat every 4 hours
Tetanus prophylaxis
Unknown or incomplete immunization and dirty wound
Tdap
Single dose
Tetanus immune globulin 250 units IM
Separate site from vaccine
Hemorrhage adjuncts and prevention
Hemorrhage adjuncts and prevention
TXA pathway in major trauma hemorrhage
If within 3 hours, initiate TXA
TXA 1 g IV over 10 minutes
Then TXA 1 g IV over 8 hours
Increased harm signal if delayed beyond 3 hours
Temperature management
Normothermia goal
Active warming if hypothermic
Calcium management during massive transfusion
Ionized calcium monitoring
Treat hypocalcemia during transfusion
Definitive management overview
Definitive management overview
Femoral neck fracture
Displaced intracapsular fracture in older adult
Arthroplasty pathway
Total hip arthroplasty selection criteria
Nondisplaced intracapsular fracture
Internal fixation pathway
Intertrochanteric fracture
Cephalomedullary nail option
Sliding hip screw option
Subtrochanteric fracture
Cephalomedullary nail typical strategy
Femoral shaft fracture
Intramedullary nailing typical strategy
External fixation damage control option
Distal femur fracture
Locking plate fixation option
Retrograde nail option
Evidence framing
AAOS hip fracture guideline provides recommendations for older adults
NICE CG124 emphasizes coordinated hip fracture programs and early surgery when appropriate
VTE prophylaxis and secondary prevention
VTE prophylaxis and secondary prevention
VTE risk recognition
Major lower extremity fracture high VTE risk
Mechanical prophylaxis
Intermittent pneumatic compression when feasible
Pharmacologic prophylaxis coordination
Enoxaparin timing per surgical plan
Hold for active bleeding or pending neuraxial anesthesia
Fragility fracture pathway
Osteoporosis evaluation referral
Vitamin D and calcium adequacy assessment
Fall risk evaluation referral
Special Populations
Pregnancy
Pregnancy
Maternal priorities
Maternal resuscitation first principle
Left uterine displacement in later gestation
Imaging considerations
Do not delay indicated imaging for maternal stabilization
Shielding when feasible
Medication considerations
Avoid NSAIDs in later pregnancy
Opioid use with fetal monitoring considerations
Obstetrics involvement
Fetal monitoring based on gestational age
Rh status assessment when indicated
Geriatric
Geriatric
Hip fracture high-risk phenotype
30-day mortality risk recognition
Delirium risk recognition
Analgesia considerations
Lower opioid starting doses
Regional anesthesia preference when available
Medical optimization priorities
Early anesthesia assessment
Early geriatric co-management where available
Disposition considerations
Admission for nearly all femur fractures
Early mobilization planning post-op
Pediatrics
Pediatrics
Mechanism patterns
High-energy trauma in older child
Non-accidental trauma consideration in young child
Immobilization options
Skin traction option for pain control
Approx 10% body weight traction reference
Thomas splint option for transfer
Analgesia dosing
Acetaminophen 15 mg/kg PO
Maximum 1000 mg per dose
Maximum 60 mg/kg per 24 hours
Ibuprofen 10 mg/kg PO
Maximum 600 mg per dose
Avoid in dehydration
Surgical pathway differences
Flexible nails in certain age groups
Spica casting in selected younger children
Background
Epidemiology
Epidemiology
Fracture patterns by age
High-energy femoral shaft fractures in younger adults
Low-energy hip fractures in older adults
Sex distribution trends
Higher hip fracture risk in older women
Mortality and morbidity signals
Hip fracture associated with substantial short-term mortality in older adults
30-day mortality reported up to about 8% in older adult cohorts
One-year mortality reported around 20% to 30% in older adult cohorts
Pathophysiology
Pathophysiology
Bleeding physiology
Medullary canal bleeding contribution
Soft tissue injury bleeding contribution
Shock risk amplification with polytrauma
Fat embolism mechanism
Marrow fat entry into venous circulation
Inflammatory cascade contribution
Osteoporotic fragility fracture mechanism
Low bone mineral density
Fall biomechanics
Therapeutic Considerations
Therapeutic considerations
Early immobilization rationale
Pain reduction
Reduced ongoing bleeding from fracture motion
Reduced secondary soft tissue injury
Regional anesthesia rationale
Opioid sparing effect
Improved early mobilization potential
Definitive fixation timing concepts
Early fixation improves pain control and mobilization in many settings
Damage control orthopedics in physiologically unstable patients
Evidence and guideline framing
NICE CG124 recommends coordinated multidisciplinary hip fracture care and early surgery when appropriate
AAOS hip fracture guideline provides evidence-based recommendations for older adults with hip fracture
Patient Discharge Instructions
Copy discharge instructions
Copy discharge instructions
Activity and weight-bearing
Weight-bearing status per orthopedics plan
Crutches or walker use training
Wound and splint care
Keep splint clean and dry
Do not insert objects into splint
Pain control
Acetaminophen schedule as directed
NSAID use only if approved
Opioid safety
No driving
No alcohol
DVT prevention instructions when prescribed
Anticoagulant adherence
Leg exercises as directed
Return to ED immediately
Increasing pain not controlled
New numbness or weakness foot
Pale or cold foot
Blue toes
New swelling calf
Chest pain
Shortness of breath
Fever
Drainage or foul odor from wound
Follow-up
Orthopedics appointment timing per plan
Primary care follow-up for osteoporosis evaluation if fragility fracture
References
Guidelines and evidence sources
Guidelines and evidence sources
AAOS Management of Hip Fractures in Older Adults clinical practice guideline published 2021
NICE CG124 Hip fracture management last updated 6 January 2023
NICE NG37 Fractures complex assessment and management published 2016
BOAST 4 Open fractures guidance
BOA and BAPRAS Standards for Open Fractures 2020
ACS TQIP Best Practices in the Management of Orthopaedic Trauma guideline
EAST Practice Management Guideline on TXA in trauma updated 2025
Peer-reviewed review data on hip fracture mortality and systems of care
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.