›Pain control regimen
›Paracetamol oral 1000 mg every 6 hours
›Maximum 4000 mg per 24 hours
›Lower maximum if liver disease or low body mass
›Ibuprofen oral 400 mg every 6 to 8 hours
›Maximum 2400 mg per 24 hours
›Avoid in CKD, GI bleed risk, anticoagulation high risk, late pregnancy
›Naproxen oral 250 mg every 12 hours
›Maximum 1000 mg per 24 hours
›Avoid in CKD and high GI risk
›Hydromorphone oral 1 mg every 4 to 6 hours as needed
›Start low in older adults
›Monitor sedation and constipation
›Morphine oral 5 mg every 4 hours as needed
›Avoid or reduce in renal impairment
›Prefer hydromorphone if CKD
›Antiemetic adjunct
›Ondansetron oral 4 mg every 8 hours as needed
›QT prolongation risk awareness
›Avoid high cumulative dosing in long QT
Immobilization and nonoperative care
›Initial management
›Sling and swathe
›Continuous wear first 1 to 2 weeks except hygiene and exercises
›Skin care and pressure points monitoring
›Early motion
›Hand, wrist, and elbow range of motion daily
›Prevents stiffness and edema
›Pendulum exercises when pain allows
›Often starts within 7 days
›Ice and elevation
›Ice 15 to 20 minutes up to 4 times daily
›Skin protection barrier
›Typical nonoperative indications
›Neer 1 part or minimally displaced surgical neck fracture
›High union rate with functional rehab
›Greater tuberosity displacement small
›Acceptable if minimal and no impingement risk
›Frail patients with high surgical risk
›Shared decision making and goals of care
Procedural and ED interventions
›Reduction scenarios
›If fracture dislocation confirmed
›Ortho consultation for reduction strategy
›Avoid repeated attempts without specialist plan
›If severe skin tenting
›Gentle alignment improvement with analgesia
›Avoid forceful manipulation
›Sedation and regional anesthesia options
›Procedural sedation for reduction when required
›Monitoring and airway readiness
›Consider older adult delirium risk
›Interscalene nerve block for analgesia
›Ultrasound guidance preferred
›Local anesthetic systemic toxicity precautions
Operative management overview
›Surgical options
›Percutaneous pinning
›Selected patterns in younger bone quality
›Pin tract infection risk
›ORIF with locking plate
›Displaced 2 part and selected 3 part
›Risk of screw penetration and stiffness
›Intramedullary nailing
›Selected surgical neck patterns
›Shoulder impingement risk
›Hemiarthroplasty
›Selected fracture patterns with salvage intent
›Tuberosity healing critical to function
›Reverse total shoulder arthroplasty
›Older adults with complex 3 part and 4 part
›Less dependence on rotator cuff integrity
›Evidence and guideline framing
›AAOS guidance supports individualized decision making for displaced fractures
›Evidence quality varies by fracture pattern and age
›Class I recommendation for urgent management of open fractures
›Antibiotics and surgical consultation time sensitive
›ACEP Level C for regional anesthesia in ED based on local expertise and resources
›Safety dependent on training and monitoring
Antibiotics and tetanus for open fracture
›Open fracture prophylaxis
›Cefazolin IV 2 g every 8 hours
›Continue until operative plan per ortho
›Allergy alternative per local protocol
›If farm injury or heavy contamination, broader coverage per ortho
›Consider anaerobic coverage
›Tetanus prophylaxis
›Tdap if immunization not up to date
›TIG if high risk wound and unknown immunization status