›Indications for reduction
›Lunate dislocation
›Any confirmed
›Median nerve symptoms
›Perilunate dislocation
›Any confirmed
›Threatened skin
›Radiocarpal dislocation
›Any confirmed
›Vascular compromise
›Contraindications or caution triggers
›Open injury with gross contamination
›Antibiotics before reduction when feasible without delaying limb saving reduction
›Suspected major vascular injury
›Immediate specialist involvement if available
›Analgesia and anesthesia
›Non opioid analgesia
›Acetaminophen PO 1000 mg
›Ibuprofen PO 600 mg
›Opioid analgesia
›Fentanyl IV 0.5 to 1 mcg/kg
›Hydromorphone IV 0.5 to 1 mg
›Procedural sedation options
›Ketamine IV 1 to 2 mg/kg
›If repeat dosing, 0.5 mg/kg
›If severe hypertension concern, alternative agent
›Propofol IV 0.5 to 1 mg/kg
›If repeat dosing, 0.25 to 0.5 mg/kg
›If hypotension risk, lower initial dose
›Etomidate IV 0.1 to 0.2 mg/kg
›If limited hemodynamic reserve, consider
›Myoclonus can complicate reduction
›Midazolam IV 0.02 to 0.05 mg/kg
›If combined with opioid, higher respiratory depression risk
›Titrate in small increments
›Evidence and guideline notes
›ACEP Level B recommendation for capnography during ED procedural sedation when feasible
›Class I recommendation for continuous pulse oximetry during moderate to deep sedation
›Reduction technique principles
›Traction and countertraction
›Finger traps traction or manual traction
›Countertraction at forearm
›Perilunate reduction concept
›Wrist extension to disengage
›Then gradual flexion with dorsal pressure on capitate
›Lunate reduction concept
›Traction with wrist extension
›Volar pressure to guide lunate dorsal to volar realignment avoidance
›Attempt limits
›If unsuccessful after 1 to 2 careful attempts, urgent specialist escalation
›Avoid repeated forceful attempts
›Post reduction requirements
›Neurovascular reassessment
›Median nerve sensory and motor
›Perfusion and pulses
›Post reduction radiographs
›True lateral confirmation
›Alignment restoration check
›Definitive immobilization
›Sugar tong or well molded volar plus dorsal splinting
›Swelling phase avoidance of circumferential cast
›Failed reduction pathway
›If persistent malalignment, urgent operative management pathway
›If persistent median nerve deficit, emergent carpal tunnel release consideration
›If worsening pain and tense compartments, compartment syndrome escalation
Open fracture medications and timing
›Antibiotics for open wrist injury
›Cefazolin IV 2 g
›Repeat every 8 hours while awaiting OR per local protocol
›If weight 120 kg or greater, 3 g dosing per local protocol
›If severe penicillin cephalosporin allergy, clindamycin IV 900 mg
›Repeat every 8 hours while awaiting OR per local protocol
›If gross contamination or farm injury, add gentamicin IV 5 mg/kg once daily per local protocol
›Renal dosing adjustment when needed
›Trough monitoring for repeat dosing
›Tetanus prophylaxis
›If unknown or incomplete immunization, tetanus vaccine
›If high risk wound and immunization uncertain, tetanus immune globulin per local protocol
›Wound care
›Sterile saline irrigation for gross debris
›Sterile dressing
›No closure in ED if deep contamination concern