Immobilization and reduction strategy
›Immobilization selection
›Sugar-tong splint
›Distal radius fractures post-reduction
›Forearm fractures requiring rotation control
›Long-arm splint
›Diaphyseal both-bone fractures
›Monteggia and Galeazzi patterns
›Short-arm splint or cast
›Stable nondisplaced distal fractures after swelling phase
›Selected pediatric stable patterns
›Reduction indications
›Angulation or displacement exceeding acceptable parameters
›Adult diaphyseal fractures typically require anatomic reduction
›Pediatric acceptable angulation depends on age and location
›Neurovascular compromise
›Immediate gentle realignment to relieve pressure
›Post-reduction neurovascular reassessment
›Skin tenting
›Reduction to protect soft tissues
›Close skin monitoring after splint
›Post-reduction checks
›Radiographs
›Confirm alignment and joint congruence
›Confirm no new displacement after splint
›Neurovascular exam
›Pulses and perfusion
›Median, ulnar, radial nerve function
›Multimodal pain control
›Paracetamol
›1000 mg PO every 6 hours
›Maximum 4000 mg per 24 hours
›Ibuprofen
›400 to 600 mg PO every 6 to 8 hours with food
›Avoid in significant renal disease or high bleeding risk
›Opioid for breakthrough pain
›Morphine PO
›5 to 10 mg PO every 4 hours as needed
›Lower starting dose in older adults
›Hydromorphone PO
›1 to 2 mg PO every 4 to 6 hours as needed
›Caution with opioid-naive patients
›Local and regional anesthesia options
›Hematoma block for distal radius fracture
›Lidocaine 1% without epinephrine
›10 to 20 mL infiltrated into fracture hematoma using sterile technique
›Maximum lidocaine dose 4.5 mg/kg without epinephrine
›Peripheral nerve block options
›Ultrasound-guided median or radial nerve block
›Local anesthetic selection per institutional protocol
›Post-block neuro exam documentation
›Procedural sedation pathways
›Ketamine IV
›Initiate 1 mg/kg IV for dissociative sedation
›If inadequate, additional 0.5 mg/kg IV doses
›Airway and monitoring per sedation policy
›Propofol IV
›Initiate 0.5 to 1 mg/kg IV bolus
›Titrate 0.25 to 0.5 mg/kg IV as needed
›Hypotension and apnea risk monitoring
›Fentanyl and midazolam IV
›Fentanyl 0.5 to 1 mcg/kg IV
›Midazolam 0.02 to 0.05 mg/kg IV
›Respiratory depression monitoring
›Antibiotics
›Gustilo Type I and II coverage
›Cefazolin IV
›2 g IV every 8 hours
›3 g IV every 8 hours if weight ≥120 kg
›Gustilo Type III or gross contamination
›Cefazolin IV regimen plus gram-negative coverage
›Gentamicin IV
›5 mg/kg IV once daily using adjusted body weight when indicated
›Renal dosing adjustments
›Farm or soil contamination concern
›Add anaerobic coverage
›Metronidazole IV
›500 mg IV every 8 hours
›Alternative per local protocol
›Severe beta-lactam allergy
›Clindamycin IV
›900 mg IV every 8 hours
›Consider gram-negative agent addition for Type III patterns
›Tetanus prophylaxis
›Immunization status review
›Tdap booster if not up to date
›Tetanus immune globulin for incomplete or unknown immunization with dirty wound
›Wound care prior to operating room
›Sterile saline irrigation
›Gross debris removal
›Avoid aggressive debridement in ED
›Sterile dressing and splint
›Moist sterile dressing if needed
›Limb immobilization for comfort and protection
Compartment syndrome actions
›Clinical suspicion pathway
›Remove constrictive items
›Split cast or loosen splint wraps
›Maintain limb at heart level
›Analgesia does not exclude diagnosis
›Pain reassessment after intervention
›Serial exams prioritized
›Escalation and definitive care
›Immediate orthopedic consultation
›Fasciotomy planning
›Pressure measurement adjunct if needed
›Supportive care
›IV fluids for rhabdomyolysis risk in delayed cases
›Renal function monitoring if concern