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
›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
›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
›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