Immediate life-saving interventions
› Immediate threats
› If respiratory distress or chest injury concern then chest imaging priority
› Chest radiograph
› POCUS pleural evaluation when available
› If tension pneumothorax concern then immediate decompression
› Needle decompression per local protocol
› Tube thoracostomy preparation
› If hard signs of vascular injury then immediate surgical escalation
› Vascular surgery notification
› CTA when not delaying operative control
› If open fracture then antibiotics and tetanus pathway without delay
› Sterile coverage
› Hemorrhage control with direct pressure
Immobilization and Splinting
› Immobilization selection
› Upper extremity options list
› Sling
› Shoulder immobilizer
› Figure of eight brace
› Posterior long arm splint
› Coaptation splint
› Typical selection for clavicle fracture
› Sling
› Shoulder immobilizer when additional comfort needed
› Principles
› Hand and wrist free for motion
› Elbow supported for comfort
› Swelling phase avoidance of tight straps
› Reassessment after immobilization
› Pain trend
› Neurovascular exam repeat
› Reduction considerations
› Routine closed reduction not performed for isolated clavicle fractures
› Outcomes not improved with manipulation in most patterns
› Pain and swelling limitation
› If threatened skin from sharp fragment then urgent orthopedics management
› Class I recommendation for emergent specialist evaluation for impending open fracture
› Avoid repeated manipulation attempts in ED
› If SC posterior dislocation suspected then specialist reduction pathway
› Reduction in monitored setting
› Surgical backup available
Open fracture medications and timing
› Antibiotics and tetanus
› Antibiotic timing
› First dose as early as feasible
› Documentation of administration time
› Antibiotic selection
› Cefazolin IV for type I and II open fracture patterns
› Adult dose 2 g IV
› If weight 120 kg or greater then 3 g IV
› If severe cephalosporin allergy then clindamycin IV
› Adult dose 900 mg IV
› If gross contamination or farm injury concern then add gram negative coverage per local protocol
› Gentamicin IV dosing per weight and renal function
› Therapeutic drug monitoring when continued
› Tetanus prophylaxis
› If unknown or fewer than 3 doses then tetanus vaccine
› If dirty wound and unknown or fewer than 3 doses then tetanus immune globulin
DVT prophylaxis when relevant
› VTE prophylaxis
› Routine pharmacologic prophylaxis not indicated for isolated upper extremity sling
› Low baseline VTE risk
› Early ambulation typical
› Consider prophylaxis when high risk and immobilized or admitted
› Active malignancy
› Prior VTE history
› Prolonged hospitalization
› Agent selection aligned with institutional protocol
› Enoxaparin prophylaxis dosing
› Mechanical prophylaxis when anticoagulation contraindicated
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