01Approach to the Critical Patient/attcp42

Immediate priorities

›Stabilization priorities

›Airway and ventilation compromise from polytrauma

›If altered mental status or impending airway compromise, RSI pathway

›Hemorrhagic shock triggers

›If SBP < 90 mmHg or shock index > 1, massive hemorrhage pathway

›Concomitant injuries pattern

›High-energy mechanism

›Fall from height

›Analgesia early

›If severe pain, IV opioid titration with monitoring

›If opioid-sparing needed, regional anesthesia pathway

›Limb-threatening checks

›Distal perfusion status

›If absent radial pulse or cool hand, emergent reduction/splinting and vascular imaging

›Compartment syndrome risk

›If escalating pain out of proportion or tense compartments, emergent surgical consult

›Open fracture contamination

›If open wound, immediate antibiotics and tetanus protocol

Key decision points

›Early stratification

›Isolated closed fracture with intact neurovascular exam

›ED splinting and outpatient ortho follow-up pathway

›Open fracture

›Immediate antibiotics

›Urgent orthopedic consult for operative debridement

›Neurovascular deficit

›Radial nerve palsy documentation

02History/hx35

Focused trauma history

›Mechanism and energy

›Mechanism details

›Direct blow

›Twisting injury

›MVC or fall from height

›Timing

›Time since injury

›Time since last oral intake if operative risk

›Open wound context

›Contaminated environment

›Farm injury

›Symptoms and function

›Pain pattern

›Pain at rest

›Pain with minimal movement

›Neurologic symptoms

›Dorsal hand numbness

›Wrist or finger extension weakness

›Vascular symptoms

›Hand coolness

›Hand color change

›Baseline risk and modifiers

›Anticoagulants and antiplatelets

›Warfarin

›DOAC use

›Bone health

›Osteoporosis

03Physical Exam/exam53

Upper extremity exam

›Inspection and alignment

›Deformity

›Varus or valgus angulation

›Shortening

›Swelling and ecchymosis

›Expanding hematoma concern

›Skin blistering

›Open wound features

›Wound size

›Visible bone

›Palpation and stability

›Tenderness localization

›Proximal third

›Middle third

›Distal third

›Crepitus

›Gentle exam only

›Compartment firmness

›Tense compartments

›Pain with passive finger stretch

Neurovascular exam

›Vascular status

›Pulses

›Radial pulse

›Ulnar pulse

›Perfusion

›Capillary refill

04Differential Diagnosis/ddx23

Traumatic upper arm pain differential

›Humeral shaft fracture diagnoses

›Closed humeral shaft fracture

›ICD-10 S42.30x

›SNOMED CT humeral shaft fracture

›Open humeral shaft fracture

›ICD-10 S42.32x

›Gustilo-Anderson grade as modifier

›Mimics and associated injuries

›Proximal humerus fracture

›Shoulder swelling and ecchymosis

›Supracondylar distal humerus fracture

›Elbow effusion

›Shoulder dislocation

›Loss of deltoid contour

›Elbow dislocation

›Obvious deformity at elbow

›Brachial artery injury

›Diminished pulses

›Radial nerve neurapraxia without fracture

›Isolated dorsoradial sensory change

›Pathologic fracture

›Minimal trauma mechanism

›Cancer history

05Laboratory Tests/lt20

Labs by context

›Minimal labs for isolated closed fracture

›No routine labs needed

›If no planned procedural sedation

›If no anticoagulant concern

›Point-of-care glucose if altered mental status

›Hypoglycemia exclusion

›Open fracture and operative pathway labs

›Baseline labs

›Complete blood count for anemia or infection context

›Electrolytes and renal function for perioperative planning

›Coagulation testing

›If anticoagulant use, INR and aPTT

›If liver disease or bleeding concern, INR

›Type and screen

›If high-energy trauma or large hematoma

›Trauma adjuncts

›Venous blood gas if shock concern

›Lactate mmol/l for perfusion trend

›Creatine kinase if crush component

›Rhabdomyolysis screening

06Diagnostic Tests/dt48

Scoring Systems

›Classification and severity tools

›AO/OTA humeral diaphysis classification

›12-A simple

›12-B wedge

›12-C complex

›Gustilo-Anderson open fracture classification

›Type I

›Type II

›Type IIIA

›Type IIIB

›Type IIIC

›Neurovascular status as functional severity marker

›Radial nerve palsy present

›Vascular compromise present

MRI

›Advanced soft tissue imaging

›Indications

›Suspected occult fracture with normal radiographs and persistent focal pain

›Suspected tendon rupture if exam suggests

›Limitations

›Not first-line for acute shaft fracture alignment decisions

›Availability and time constraints in acute trauma

CT

›Cross-sectional imaging

›Indications

›Suspicion of intra-articular extension at shoulder or elbow

›Preoperative planning for comminution

07Disposition/dispo26

Level of care decisions

›Discharge criteria

›Closed fracture

›Pain controlled with oral regimen

›Intact distal neurovascular status

›Acceptable alignment in splint

›No threatened skin

›No progressive swelling

›Reliable follow-up within 1 week

›Ortho appointment arranged

›Admission or transfer criteria

›Open fracture

›Urgent orthopedic management

›IV antibiotics ongoing

›Neurovascular compromise

›Vascular surgery consult or transfer if unavailable

›Compartment syndrome concern

›Emergent operative evaluation

›Polytrauma

›Trauma service admission

›Follow-up timing

›Nonoperative management pathway

›Ortho follow-up 3 to 7 days

›Repeat radiographs at follow-up

›Radial nerve palsy pathway

›Early ortho follow-up

›Document baseline deficits and evolution

08Treatment/t87

Immobilization and reduction

›Initial immobilization

›Coaptation splint or hanging arm cast option

›Splint choice based on swelling and comfort

›Post-splint radiographs for alignment

›Sling and swathe adjunct

›Comfort

›Shoulder support

›Reduction considerations

›Closed reduction attempt if severe angulation or skin tenting

›If neurovascular compromise, prioritize realignment and splint

›Post-reduction neurovascular exam documentation

Analgesia and sedation

›Multimodal analgesia

›Acetaminophen PO 1000 mg q6h

›Maximum 4000 mg per 24 hours

›Lower maximum in liver disease

›Ibuprofen PO 400 mg q6 to 8h

›Avoid in CKD, GI bleed risk, anticoagulation as clinically appropriate

›Maximum 2400 mg per 24 hours

›Opioid for breakthrough pain

›Morphine IV 0.05 mg/kg

›Titrate every 10 to 15 minutes to effect

›Respiratory monitoring

›Hydromorphone IV 0.01 mg/kg

›Titrate every 10 to 15 minutes to effect

›Avoid coadministration with other sedatives when possible

›Procedural sedation if reduction required

›Ketamine IV 1 mg/kg

›Additional 0.5 mg/kg doses as needed

›Continuous cardiorespiratory monitoring

›Propofol IV 0.5 mg/kg

›Titrate 0.25 mg/kg every 1 to 3 minutes

›Hypotension risk monitoring

Antibiotics and tetanus

›Open fracture antibiotics

›Cefazolin IV 2 g

›Repeat every 8 hours while awaiting operative care

›If weight > 120 kg, 3 g dosing consideration per institutional protocol

›If severe beta-lactam allergy, clindamycin IV 900 mg

›Repeat every 8 hours

›C difficile risk context

›If gross contamination or farm injury, add gram-negative coverage per protocol

›Gentamicin IV 5 mg/kg

›Renal dosing adjustments

›Tetanus prophylaxis

›Tdap if immunization unknown or not up to date

›Clean wound threshold

›Dirty wound threshold

›Tetanus immune globulin if incomplete immunization and dirty wound

›Administer at separate site from vaccine

Operative versus nonoperative pathways

›Nonoperative management indications

›Closed fracture with acceptable alignment

›Varus or valgus angulation within local orthopedic thresholds

›No progressive neurovascular deficit

›Functional bracing transition

›Sarmiento brace after swelling subsides

›Early elbow and shoulder ROM as guided

›Operative management indications

›Open fracture

›Irrigation and debridement timing

›Fixation planning

›Vascular injury

›Emergent repair and stabilization coordination

›Floating elbow or ipsilateral forearm fractures

›Stability needs

›Failed nonoperative management

›Progressive displacement

›Nonunion concern

›Pathologic fracture

›Oncology and ortho coordination

Radial nerve palsy management

›Initial palsy with closed fracture

›Observation pathway commonly appropriate

›Document baseline deficits

›Serial exams

›Splinting for wrist drop

›Cock-up wrist splint

›Hand therapy referral planning

›Secondary palsy after manipulation

›Urgent orthopedic consult

›Consider entrapment

›Consider iatrogenic injury

Vascular injury pathway

›Hard signs escalation

›If pulseless limb, emergent consultation and CTA if not delaying definitive care

›Immediate splint realignment first if deformity severe

›Avoid prolonged ischemia time

›Antithrombotic considerations

›Individualized with vascular team

›Bleeding risk context

›Operative timing

09Special Populations/sp33

Pregnancy

›Pregnancy-specific considerations

›Imaging safety

›Plain radiographs with shielding when feasible

›CT only if benefits outweigh risks

›Analgesia considerations

›Acetaminophen preferred baseline

›NSAID avoidance in later pregnancy context

›Trauma pathway

›Maternal stabilization priority

›Fetal assessment per gestational age

Geriatric

›Older adult considerations

›Fragility fracture context

›Osteoporosis evaluation referral

›Vitamin D and calcium counseling pathway

›Medication safety

›Opioid sensitivity and delirium risk

›NSAID renal and GI risk

›Healing risk

›Higher nonunion risk factors

›Malnutrition screening

Pediatrics

›Pediatric considerations

›Nonaccidental trauma screen when appropriate

›Inconsistent history

›Additional injuries

›Growth plate and adjacent injury screening

10Background/b32

Epidemiology

›Frequency and associations

›Humeral shaft fractures as adult long-bone injury subset

›Bimodal distribution

›High-energy trauma in younger adults

›Common associated injuries

›Ipsilateral shoulder injury

›Ipsilateral elbow injury

›Nerve injury association

›Radial nerve most commonly affected

Pathophysiology

›Mechanisms and anatomy

›Diaphyseal fracture patterns

›Spiral

›Transverse

›Comminuted

›Radial nerve course vulnerability

›Spiral groove proximity

›Distal third risk near lateral intermuscular septum

›Healing biology

›Callus formation with relative stability

›Nonunion risk with instability and smoking

Therapeutic Considerations

›Management principles

›Alignment and function goals

›Preserve shoulder and elbow ROM

›Pain control enabling mobilization

›Nonoperative success concept

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Discharge instructions set

›Immobilization care

›Keep splint clean and dry

›Elevation of arm above heart when resting

›Activity limits

›No lifting or pushing with injured arm

›Finger and hand motion exercises if allowed by splint

›Pain control plan

›Acetaminophen dosing schedule

›NSAID use only if safe for kidneys and stomach

›Opioid only for breakthrough pain

›Return to ED immediately

›New numbness or weakness in hand

›Fingers turning blue or very pale

›Increasing swelling with severe pain not controlled by meds

›Splint feels too tight or new severe pain with finger movement

›Fever or worsening wound drainage

›Follow-up plan

›Orthopedic follow-up within 3 to 7 days

›Repeat imaging at follow-up as directed

›Wound care for open wounds

›Keep dressing intact until reviewed

›Antibiotics completion if prescribed

12References/r14

Clinical guidelines and evidence sources

›Orthopedic trauma guidance

›AAOS and orthopedic trauma society resources on humeral shaft fracture management

›Nonoperative functional bracing principles

›Operative indications

›Open fracture prophylaxis consensus

›Early IV antibiotics

›Tetanus prophylaxis standards

›Emergency medicine references

›ACEP procedural sedation clinical policy for ED sedation practices

›Monitoring standards

›Agent safety considerations

›ACEP Level C consensus for documentation and reassessment standards in extremity trauma

›Neurovascular checks pre- and post-immobilization

›Discharge safety netting

Evidence & Review

Evidence & Review