01Approach to the Critical Patient/attcp36

Immediate threats

›Immediate threats and triggers

›Hemorrhage and shock

›If uncontrolled bleeding, tourniquet and massive transfusion protocol

›If hypotension with long bone fracture, search for additional bleeding source

›Open fracture contamination

›If open wound near fracture, treat as open fracture until proven otherwise

›If gross contamination, immediate irrigation and sterile dressing

›Acute limb ischemia

›If absent pulses or cool pale foot, immediate reduction and vascular surgery consult

›If hard signs of vascular injury, immediate OR activation

›Compartment syndrome

›If pain out of proportion or escalating opioid need, immediate fasciotomy pathway activation

›If neurologic deficit progression, treat as impending compartment syndrome

Monitoring and targets

›Monitoring and targets

›Vitals and perfusion

›Persistent tachycardia as occult blood loss marker

›Capillary refill and skin temperature trends

›Limb perfusion documentation

›Dorsalis pedis pulse quality

›Posterior tibial pulse quality

›Motor function toe extension and flexion

›Sensation first dorsal web space

›Pain control and reassessment cadence

›Recheck neurovascular status after analgesia and after splinting

›Escalation threshold for pain not improving with immobilization

02History/hx29

Presentation and mechanism

›Presentation and mechanism

›Mechanism category

›High energy motor vehicle collision

›Fall from height

›Sports twisting injury

›Direct blow

›Timing and evolution

›Time since injury

›Increasing pain or swelling since injury

›Open injury indicators

›Wound at impact site

›Foreign body or contamination

›Neurovascular symptoms

›Numbness or tingling in foot

›Weakness moving toes

›Coldness or color change

Risks and comorbidities

›Risks and comorbidities

›Bleeding and clot risks

›Anticoagulant use

›Prior venous thromboembolism

›Infection risks

›Diabetes mellitus

›Immunosuppression

›Bone health and fracture risk

›Osteoporosis history

›Prior stress fracture

03Physical Exam/exam47

Limb and wound assessment

›Limb and wound assessment

›Deformity and alignment

›Tibial bowing or angulation

›Rotational malalignment

›Skin and soft tissue

›Open wound size and location

›Skin tenting

›Blisters and threatened skin

›Swelling and compartments

›Tense compartments

›Pain with passive toe stretch

›Palpation pattern

›Tibial crest tenderness distribution

›Fibular head tenderness

›Medial malleolus tenderness

›Lateral malleolus tenderness

Neurovascular exam

›Neurovascular exam

›Pulses and perfusion

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Skin temperature symmetry

›Motor function

›Ankle dorsiflexion

›Great toe extension

›Plantarflexion

04Differential Diagnosis/ddx29

Critical and limb threatening

›Critical and limb threatening

›Compartment syndrome SNOMED CT 78963001

›Disproportionate pain

›Pain with passive stretch

›Acute arterial injury SNOMED CT 312052005

›Hard signs ischemia

›ABI abnormal

›Open fracture infection risk ICD-10 S82.20 with open wound

›Gross contamination

›Delayed antibiotics

Mimics and related injuries

›Mimics and related injuries

›Ankle fracture ICD-10 S82.5

›Malleolar tenderness

›Ankle instability

›Tibial plateau fracture ICD-10 S82.1

›Knee effusion

›Inability to bear weight

›Tibial pilon fracture ICD-10 S82.87

›Severe ankle swelling

›Axial load mechanism

›Maisonneuve injury

›Proximal fibula tenderness with ankle injury

›Syndesmotic pain

›Stress fracture ICD-10 M84.36

›Activity related pain

›Focal tenderness without trauma

05Laboratory Tests/lt24

Core labs for high risk presentations

›Core labs for high risk presentations

›Hemorrhage and operative planning

›Complete blood count for anemia and baseline

›Type and screen for open fracture or high energy injury

›Renal and electrolyte status

›Basic metabolic panel for contrast planning and dehydration

›Potassium for crush risk and rhabdomyolysis concern

›Coagulation profile

›INR for anticoagulant use

›aPTT for heparin exposure

Infection and open fracture considerations

›Infection and open fracture considerations

›Baseline inflammatory markers

›Not required for acute closed fracture

›Consider if delayed presentation with systemic symptoms

›Tetanus status planning

›Vaccine history and last booster interval

›Immunoglobulin indication for unknown status and dirty wound

Compartment syndrome and crush adjuncts

›Compartment syndrome and crush adjuncts

›Rhabdomyolysis risk

›Creatine kinase for crush or prolonged entrapment

›Urinalysis for heme positive with few RBC

›Metabolic severity

›Venous blood gas for severe crush with acidosis concern

›Lactate for shock or severe tissue injury

06Diagnostic Tests/dt54

Scoring Systems

›Scoring systems and decision frameworks

›Open fracture severity

›Gustilo Anderson classification for open fractures

›Higher grade correlates with infection risk and operative urgency

›Soft tissue injury severity

›Tscherne classification for closed fracture soft tissue injury

›High grade correlates with swelling and wound complication risk

›Compartment syndrome objective support

›Compartment pressure measurement adjunct

›Delta pressure diastolic minus compartment pressure

›If delta pressure <= 30 mmHg, high risk for compartment syndrome

›Vascular injury screening

›Ankle brachial index after reduction and splinting

›If ABI < 0.9, CTA lower extremity consideration

MRI

›MRI indications and limitations

›Stress fracture and occult fracture

›Persistent focal tibial pain with negative radiographs

›Early detection of bone marrow edema

›Ligament and meniscus injury

›Suspected tibial plateau injury pattern with unstable knee

›Multi ligament injury assessment

›Limitations

›Not first line in acute unstable trauma

›Time and availability constraints in ED setting

CT

›CT indications and protocol

07Disposition/dispo23

Level of care and admission criteria

›Level of care and admission criteria

›Immediate operative or ICU pathway

›Open fracture requiring urgent debridement

›Compartment syndrome concern

›Vascular injury concern

›Inpatient admission indications

›Displaced tibial shaft fracture requiring operative fixation planning

›Intractable pain despite immobilization

›Inability to safely ambulate with assistive devices

›Transfer criteria

›Need for ortho trauma center

›Need for vascular surgery capability

Discharge criteria for selected cases

›Discharge criteria for selected cases

›Appropriate fracture patterns

›Isolated nondisplaced fibular shaft fracture with stable ankle

›Stable nondisplaced tibial stress fracture without neurovascular issues

›Safety checks

›Normal neurovascular exam after immobilization

›Pain controlled on oral regimen

›Reliable follow up within 48 to 72 hours when indicated

›Return precautions comprehension

›Compartment syndrome warnings reviewed

›Wound infection warnings reviewed

08Treatment/t61

Analgesia and immobilization

›Analgesia and immobilization

›Analgesic strategy

›Acetaminophen oral for baseline pain control

›NSAID use risk balance for fracture healing and bleeding risk

›Opioid short course for severe pain

›Regional anesthesia consideration when expertise available

›Immobilization principles

›Long leg posterior splint for tibial shaft fracture

›Sugar tong or stirrup addition for distal tibia and ankle stability

›Padding for swelling accommodation

›Limb elevation above heart when feasible

Reduction and alignment

›Reduction and alignment

›Indications

›Gross deformity

›Neurovascular compromise

›Skin tenting

›Post reduction reassessment

›Pulses and perfusion recheck

›Motor and sensory recheck

›Post reduction imaging

›Repeat radiographs for alignment confirmation

›CT if articular involvement suspected after reduction

Open fracture bundle

›Open fracture bundle

›Immediate wound care

›Sterile saline irrigation for gross contamination

09Special Populations/sp32

Pregnancy

›Pregnancy considerations

›Maternal stabilization priority

›Trauma evaluation with maternal ABC focus

›Left lateral tilt for advanced gestation when feasible

›Imaging

›Radiography with shielding when appropriate

›CT when maternal benefit outweighs fetal risk

›Medications

›Avoid NSAIDs in later pregnancy

›Opioid use short duration with obstetric coordination

›Rh status

›Rh negative patients with trauma consideration for Rh immune globulin per obstetric guidance

Geriatric

›Geriatric considerations

›Fragility and comorbidity

›Lower energy mechanisms can still produce significant injury

›Higher risk delirium with opioids

›Skin and swelling

›Higher risk skin breakdown under splints

›Frequent reassessment for pressure points

›Disposition bias

›Lower threshold for admission if unsafe mobility

›Early PT and OT planning

Pediatrics

›Pediatrics considerations

›Growth plate injury

›Salter Harris injury consideration near ankle and knee

10Background/b34

Epidemiology

›Epidemiology

›Mechanism patterns

›Tibial shaft fractures commonly high energy in adults

›Stress fractures associated with repetitive loading

›Complication frequency themes

›Compartment syndrome risk higher in tibial shaft fractures

›Open fracture risk higher with high energy mechanisms

›Associated injury patterns

›Knee and ankle involvement risk with spiral and distal fractures

›Vascular injury risk with fracture dislocation patterns

Pathophysiology

›Pathophysiology

›Bone and soft tissue injury coupling

›Tibial subcutaneous border predisposes to open injury

›Swelling increases compartment pressure in closed fascial spaces

›Vascular compromise mechanisms

›Intimal injury from stretch or shear

›Compression from hematoma or displaced fragments

›Pain generation

›Periosteal injury as major pain driver

›Ischemia as pain amplifier in compartment syndrome

Therapeutic Considerations

›Therapeutic considerations

›Antibiotics in open fractures

›Early IV antibiotics associated with lower infection rates

›Broadening coverage based on Gustilo grade and contamination

›Immobilization rationale

11Patient Discharge Instructions/pdi23

Copy discharge instructions

›Discharge instructions for tibia fibula fracture

›Immobilization and activity

›Keep splint clean and dry

›Non weight bearing unless explicitly cleared

›Elevation as much as possible for first 48 hours

›Pain control

›Acetaminophen as directed

›Prescribed pain medicine only as directed

›Avoid alcohol or driving while taking opioids

›Wound care for open injuries

›Do not remove dressings unless instructed

›Watch for increasing redness or drainage

›Return to ED immediately

›Increasing pain not relieved by medicine and elevation

›New numbness or tingling in foot

›Weakness moving toes

›Foot becoming cold or pale

›Splint feels too tight with worsening swelling

›Fever or chills with wound concerns

›Follow up

›Orthopedics appointment timing as provided

›Repeat imaging plan if instructed

›Crutch or walker safety review

12References/r13

Guidelines and key sources

›Guidelines and key sources

›Open fracture antibiotic timing recommendations from orthopedic trauma consensus statements

›Early IV antibiotics prioritized for infection reduction

›Antibiotic selection stratified by Gustilo Anderson grade

›Compartment syndrome clinical diagnosis principles from orthopedic and emergency medicine references

›Serial exam emphasis for evolving presentations

›Delta pressure threshold support for equivocal cases

›Trauma care principles for limb perfusion assessment and vascular injury screening

›ABI screening threshold 0.9 for further vascular imaging consideration

›Hard signs prompting immediate operative or vascular intervention

›Evidence grading conventions

›ACEP Level C when evidence limited and expert consensus guides ED actions

›Class I and II recommendations from specialty society consensus where applicable

Evidence & Review

Evidence & Review