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
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