Immobilization and weight bearing
›Mechanical management
›Immobilization choices
›Hard-soled shoe for stable nondisplaced shaft fractures
›Weight bearing as tolerated if pain allows and no Lisfranc concern
›Walking boot for most nondisplaced fractures with significant pain
›Protected weight bearing
›Posterior short leg splint for more painful or unstable patterns
›Non-weight-bearing if displacement risk or multiple fractures
›Reduction indications
›Significant angulation or displacement on radiograph
›If reduction performed, post-reduction radiographs
›Fifth metatarsal specifics
›Tuberosity avulsion
›Boot or hard-soled shoe
›Weight bearing as tolerated
›Junction fracture and proximal diaphyseal stress pattern
›Non-weight-bearing short leg splint or cast pathway per specialist preference
›Higher nonunion risk counseling
›Multimodal pain regimen
›Acetaminophen
›Adult dosing
›1000 mg PO every 6 to 8 hours as needed
›Maximum 4000 mg per day
›Maximum 3000 mg per day in chronic alcohol use or frailty
›Pediatrics dosing
›15 mg per kg PO every 6 hours as needed
›Maximum 75 mg per kg per day
›NSAID option when not contraindicated
›Ibuprofen
›Adult dosing
›400 mg PO every 6 hours as needed
›Maximum 2400 mg per day without specialist direction
›Pediatrics dosing
›10 mg per kg PO every 6 to 8 hours as needed
›Maximum 40 mg per kg per day
›Naproxen
›Adult dosing
›250 mg PO twice daily as needed
›Maximum 1000 mg per day
›Opioid for severe pain despite above
›Oxycodone immediate release
›Adult dosing
›2.5 mg PO every 6 hours as needed
›Use lowest effective dose and shortest duration
›Hydromorphone
›Adult dosing
›1 mg PO every 6 hours as needed
›Avoid in opioid-naive when alternatives adequate
›Antiemetic if opioid used
›Ondansetron
›Adult dosing
›4 mg ODT or PO every 8 hours as needed
›Pediatrics dosing
›0.15 mg per kg PO every 8 hours as needed
›Analgesia cautions
›NSAID avoidance or caution
›Active GI bleed or high-risk ulcer history
›Advanced chronic kidney disease
›Heart failure exacerbation risk
›Opioid safety
›Avoid co-prescribing sedatives when possible
›Driving and impairment counseling
›Reduction support
›If reduction required, sedation pathway or regional anesthesia
›Procedural sedation per local protocol
›Regional block option
›Ankle block by trained clinician
›Lidocaine 1 percent without epinephrine
›Maximum 4.5 mg per kg
›Bupivacaine 0.25 percent
›Maximum 2.5 mg per kg
›Wound care for associated lacerations
›If open fracture suspected, avoid primary closure before orthopedics direction
›Sterile dressing and splint
›Tetanus update
Antibiotics and tetanus for open fractures
›Open fracture infection prophylaxis
›First-generation cephalosporin coverage
›Cefazolin
›Adult dosing
›2 g IV once then every 8 hours until operative care
›Pediatrics dosing
›30 mg per kg IV every 8 hours
›If severe beta-lactam allergy
›Clindamycin
›Adult dosing
›600 mg IV every 8 hours
›Pediatrics dosing
›10 mg per kg IV every 8 hours
›If gross contamination or farm injury
›Add gram-negative coverage per local protocol
›Gentamicin dosing per weight and renal function with pharmacy support
›Tetanus prophylaxis
›Vaccine status review
›Booster if indicated
›Tetanus immune globulin if indicated for dirty wound and incomplete immunization
›Evidence framing
›Early antibiotics in open fractures associated with lower infection risk
›Class I recommendation by trauma and orthopedic consensus statements