Reduction and immobilization
›Closed reduction pathway
›Analgesia and sedation readiness
›Pre oxygenation and suction available
›Airway backup plan
›Reduction technique principles
›Inline traction with countertraction
›Gentle flexion to reduce posterior displacement
›Post reduction steps
›Immediate pulse and Doppler reassessment
›Post reduction radiographs
›Immobilization strategy
›Posterior long leg splint
›Neutral rotation
›Padding to protect skin
›External fixation consideration
›Gross instability
›Associated fracture requiring spanning fixator
Analgesia and procedural sedation
›Opioid analgesia options
›Fentanyl IV 0.5 to 1 mcg/kg
›Repeat 0.5 mcg/kg every 5 to 10 minutes as needed
›Max dose per local policy and respiratory status
›Morphine IV 0.05 to 0.1 mg/kg
›Repeat 0.05 mg/kg every 10 to 15 minutes as needed
›Caution hypotension and respiratory depression
›Dissociative sedation option
›Ketamine IV 1 to 2 mg/kg
›Additional 0.5 mg/kg bolus as needed
›Emergence reaction mitigation per local protocol
›Ketamine IM 4 to 5 mg/kg when no IV access
›Onset delay consideration
›Airway monitoring continuous
›Deep sedation option where appropriate
›Propofol IV 0.5 to 1 mg/kg initial
›Repeat 0.25 to 0.5 mg/kg every 1 to 3 minutes to effect
›Hypotension and apnea risk
›Etomidate IV 0.1 to 0.2 mg/kg
›Myoclonus possibility
›Transient adrenal suppression consideration
›Regional anesthesia adjunct where trained
›Femoral nerve block local anesthetic dosing per policy
›Avoid intravascular injection precautions
›Documentation of neurovascular baseline before block
Vascular injury management
›Hard signs pathway
›If hard signs persist after reduction then emergent vascular surgery activation
›Operative exploration or urgent CTA per vascular recommendation
›Class I recommendation based on expert consensus for no delay in revascularization with hard signs
›Abnormal ABI or soft signs pathway
›CTA lower extremity
›Vascular surgery involvement early
›Anticoagulation only if directed by vascular surgery
›Post reperfusion monitoring
›Compartment syndrome surveillance
›Low threshold for fasciotomy consult
›Class I recommendation based on expert consensus for fasciotomy when compartment syndrome suspected
Open injury and infection prophylaxis
›Antibiotics for open dislocation
›Cefazolin IV 2 g
›Repeat dosing per operative timing and renal function
›Add gram negative coverage for severe contamination per local protocol
›Penicillin allergy alternative per local protocol
›Clindamycin IV dosing per protocol
›Vancomycin IV for MRSA risk per protocol
›Tetanus prophylaxis
›Tdap booster when indicated
›Dirty wound with incomplete series then TIG per protocol
›Document immunization status