›Volume 5-10 mL for ankle fractures
›Allow 5-10 minutes for onset before manipulation
›Alternative to procedural sedation for cooperative patients
Procedural sedation for closed reduction
›Indications for procedural sedation
›Displaced fracture requiring closed reduction attempt
›Age and cooperation level assessment
›Younger children typically require sedation
›Pre-sedation assessment
›NPO status documentation
›Airway assessment
›Consent from parent or guardian
›Ketamine IV sedation
›Dose: 1-2 mg/kg IV over 1-2 minutes
›Onset 1-5 minutes
›Duration 10-20 minutes
›Adjunct midazolam 0.05 mg/kg IV to reduce emergence reactions
›Maximum 2 mg in young children
›Antisialogogue consideration: glycopyrrolate 0.01 mg/kg IV
›Reduces hypersalivation associated with ketamine
›Propofol IV sedation
›Dose: 1-2 mg/kg IV titrated to effect
›Onset < 1 minute
›Short recovery
›Hypotension and apnea monitoring required
›Airway equipment at bedside
›Anesthesia backup if high-risk airway
›Nitrous oxide inhalation
›50-70% nitrous oxide in oxygen
›Self-administered mask technique in cooperative children
›Onset 3-5 minutes, offset rapid
Closed reduction technique
›Reduction principles
›Reverse the mechanism of injury
›External rotation mechanism — apply internal rotation correction
›Compression — apply traction and angulation correction
›Minimize manipulation attempts
›Multiple attempts increase physeal damage
›Maximum 2-3 gentle attempts
›If unsuccessful, proceed to ORIF
›Post-reduction assessment
›Repeat neurovascular examination
›Document immediately after reduction
›Any deterioration requires urgent re-evaluation
›Post-reduction plain films
›Two orthogonal views
›CT to assess articular step-off after reduction
›Acceptable reduction criteria
›Articular step-off < 2 mm
›Physeal alignment restored
›Nondisplaced or minimally displaced SH III
›Percutaneous fixation with cannulated screws
›Screws placed parallel to the physis (epiphyseal fixation)
›Transphyseal screws avoided when possible to minimize physeal damage
›Smooth Kirschner wires in younger children with significant growth remaining
›Displaced SH III
›Open reduction and internal fixation (ORIF)
›Standard of care for articular step-off >= 2 mm
›Articular congruity restoration primary goal
›Growth plate damage minimization secondary goal
›Implant selection
›Epiphyseal cannulated screws parallel to physis preferred
›Absorbable pins in younger children to avoid second surgery for removal
›Avoid crossing physis with screws whenever possible
›Juvenile Tillaux fracture specific management
›ORIF when displacement >= 2 mm
›Single cannulated screw through epiphysis
›Placed parallel to and not crossing the physis
›Near-skeletal-maturity patients
›Growth consequences minimal
›Joint congruity still requires anatomic reduction
Antibiotic prophylaxis for open fractures
›Gustilo-Anderson Classification I-II
›Cefazolin IV 1-2 g every 8 hours (30 mg/kg in children, max 2 g)
›Initiated within 1 hour of injury recognition
›Continue for 24 hours post-operatively
›Add gram-negative coverage for contaminated wounds (Gustilo III)
›Gentamicin 5 mg/kg IV daily or divided every 8 hours
›Metronidazole 500 mg IV every 8 hours for fecal contamination
›Penicillin allergy: clindamycin 900 mg IV every 8 hours (adults)
›Pediatric clindamycin 10 mg/kg IV every 6-8 hours
Post-reduction immobilization
›Cast selection by fracture type
›Ankle SH III (Tillaux): short-leg walking cast when nonoperative
›Non-weight-bearing for 4-6 weeks
›Transition to weight-bearing when pain-free and healing confirmed
›Distal femoral SH III: long-leg cast or hinged knee brace
›Non-weight-bearing for 4-6 weeks typically
›ROM exercises after initial healing phase
›Cast window for wound monitoring in open fractures
›Daily wound inspection during initial healing