Immediate life-saving interventions
›Limb-threatening conditions
›If pulseless limb, immediate reduction attempt if dislocated
›Reassess pulses immediately after reduction
›If persistent pulseless limb, emergent ortho and vascular surgery
›If open fracture suspected, antibiotics and tetanus pathway without delay
›Cover wound with sterile saline dressing
›If compartment syndrome concern, emergent surgical consultation
›Splint loosening and reassessment if tight
Immobilization and Splinting
›Splinting strategy
›Upper extremity options
›posterior long arm
›sugar tong
›coaptation
›ulnar gutter
›radial gutter
›volar wrist
›thumb spica
›Typical selection for coronoid fracture
›posterior long arm splint
›Elbow flexion about 90 degrees if stable and tolerated
›Forearm position based on stability
›Supination preference for posterolateral instability patterns
›Pronation preference for varus posteromedial patterns
›Immobilization principles
›Avoid circumferential casting in acute swelling phase
›Joint immobilization for instability
›Neurovascular reassessment after splint placement
›Splint application checks
›Two-finger tightness check at wrap
›Extra padding at olecranon and epicondyles
›Post-application motor and sensory reassessment
›Reduction indications
›Elbow dislocation or subluxation with coronoid fracture
›Neurovascular compromise
›Threatened skin
›Incongruent joint on imaging
›Contraindications or caution
›Suspected vascular injury requiring immediate specialist involvement
›Suspected physeal injury in pediatrics
›Analgesia and anesthesia
›Non-opioid analgesia options
›Acetaminophen PO 1000 mg once then 650 to 1000 mg every 6 hours as needed
›Ibuprofen PO 400 to 600 mg every 6 hours as needed if no contraindication
›Opioid titration options
›Fentanyl IV 25 to 50 mcg every 5 minutes to effect
›Morphine IV 2 to 4 mg every 5 to 10 minutes to effect
›Regional anesthesia options
›Intra-articular lidocaine as adjunct in select cases
›Brachial plexus block by trained clinician and local protocol
›Procedural sedation pathway
›Ketamine IV 1 to 2 mg/kg
›Additional 0.5 mg/kg every 5 to 10 minutes as needed
›Continuous cardiorespiratory monitoring with capnography when used
›Propofol IV 0.5 to 1 mg/kg initial
›Additional 0.25 to 0.5 mg/kg every 2 to 3 minutes as needed
›Hypotension and respiratory depression risk
›Etomidate IV 0.1 to 0.15 mg/kg
›Additional 0.05 mg/kg as needed
›Myoclonus and adrenal suppression considerations
›Technique principles
›Traction and countertraction
›Gentle sustained force
›Reverse mechanism as appropriate
›Avoid repeated forceful attempts
›Post-reduction requirements
›Immediate neurovascular re-check
›Post-reduction radiographs
›Stability assessment through gentle arc when safe
›Immobilization in position of best stability
›Failed reduction pathway
›Persistent neurovascular deficit triggers immediate escalation
›Irreducible deformity triggers urgent orthopedics
›Worsening pain or tight compartments triggers compartment syndrome evaluation
Open fracture medications and timing
›Antibiotics and tetanus pathway
›Antibiotic timing
›First dose as soon as possible
›Gustilo type I or II suspected
›Cefazolin IV 2 g every 8 hours
›If severe beta-lactam allergy, clindamycin IV 600 to 900 mg every 8 hours
›Gustilo type III or heavy contamination suspected
›Cefazolin IV 2 g every 8 hours
›Add gentamicin IV 5 to 7 mg/kg once daily per local protocol
›Farm contamination concern
›Add penicillin G IV 4 million units every 4 hours
›Tetanus prophylaxis
›Tdap if immunization unknown or not up to date
›Tetanus immune globulin if unimmunized or unknown with dirty wound
DVT prophylaxis when relevant
›VTE considerations
›Upper extremity immobilization alone
›Routine pharmacologic prophylaxis usually not indicated
›High-risk scenarios
›Polytrauma
›Prolonged immobilization with additional risk factors
›Planned operative management with inpatient admission
›Documentation
›Risk-benefit rationale aligned to local protocol