Immobilization principles
›Splinting strategy
›Position of function
›Wrist slight extension
›MCP flexion 70 to 90 degrees when gutter used
›Buddy taping indications
›Stable non displaced fractures
›No malrotation
›Gutter splint indications
›Unstable fracture patterns
›Post reduction immobilization
›Duration planning
›Early motion when stable to reduce stiffness
›Hand therapy referral when ROM risk high
›Closed reduction considerations
›Indications
›Angulation affecting function
›Rotational deformity
›Post reduction checks
›Cascade and rotation
›Neurovascular status
›Post reduction imaging
›Confirm alignment in 2 views
›Document stability in splint
›Oral analgesics
›Acetaminophen
›Adults 1000 mg PO once
›Maximum 4000 mg per 24 hours
›Maximum 3000 mg per 24 hours if chronic alcohol use or liver disease risk
›Pediatrics 15 mg per kg PO once
›Maximum 1000 mg per dose
›Maximum 60 mg per kg per 24 hours
›Ibuprofen
›Adults 600 mg PO once
›Repeat every 6 hours as needed
›Maximum 2400 mg per 24 hours in most ED discharge plans
›Pediatrics 10 mg per kg PO once
›Repeat every 6 to 8 hours as needed
›Maximum 40 mg per kg per 24 hours
›Regional anesthesia
›Digital nerve block
›Lidocaine 1 percent without epinephrine 3 mL to 5 mL total
›Maximum lidocaine dose 5 mg per kg
›Aspirate before injection
›Bupivacaine 0.25 percent 3 mL to 5 mL total
›Maximum bupivacaine dose 2 mg per kg
›Longer duration option
›Procedural sedation pathway
›Severe pain or multiple digits
›Local block inadequate
›Reduction not tolerated
›Open fracture antibiotic options
›Cefazolin
›Adults 2 g IV once
›Repeat every 8 hours if ongoing inpatient care
›Add gram negative coverage if severe contamination
›Pediatrics 25 mg per kg IV once
›Maximum 2000 mg
›Repeat every 8 hours if ongoing inpatient care
›Penicillin allergy option
›Clindamycin
›Adults 600 mg IV once
›Repeat every 8 hours if ongoing inpatient care
›Add gram negative agent if indicated
›Pediatrics 10 mg per kg IV once
›Maximum 600 mg
›Repeat every 8 hours if ongoing inpatient care
›Bite wound coverage
›Amoxicillin clavulanate
›Adults 875 mg PO once
›Twice daily course when outpatient
›Typical duration 5 days to 7 days
›Pediatrics 22.5 mg per kg amoxicillin component PO once
›Twice daily course when outpatient
›Maximum 875 mg per dose
›Tetanus prophylaxis
›Immunization status review
›Clean minor wound booster if more than 10 years
›Dirty wound booster if more than 5 years
›Tetanus immune globulin indications
›Unknown or incomplete immunization and dirty wound
›Open fracture with contamination and no documented series
Evidence levels and recommendations
›Consensus based recommendations
›Class I expert consensus for urgent antibiotics in open fractures
›Earlier administration associated with lower infection risk
›Do not delay for imaging or consult
›Class I expert consensus for malrotation correction
›Malrotation poorly tolerated functionally
›Requires reduction or operative fixation
›ACEP Level C style consensus for routine x ray imaging in suspected fracture
›Three view hand or finger series preferred
›Post reduction imaging recommended