Immediate life-saving interventions
›Immediate threats
›If open fracture suspected, initiate open fracture pathway
›Sterile saline moist dressing
›Broad spectrum antibiotics timing within 60 minutes goal
›Tetanus prophylaxis
›If neurovascular compromise, urgent reduction and splinting
›Post intervention pulse and sensation documentation
›Immediate orthopedics escalation if deficit persists
›If compartment syndrome concern, emergent escalation
›Splint loosening and elevation to heart level
›Immediate surgical consultation
Immobilization and Splinting
›Immobilization selection
›Walking boot
›Preferred for most nondisplaced shaft fractures
›Allow swelling accommodation
›Rigid sole shoe
›Alternative for minimal pain and stable alignment
›Activity limitation reinforced
›Posterior short leg plus stirrup
›If significant swelling or pain
›If concern for associated ankle injury
›Immobilization principles
›Swelling phase avoidance of circumferential casting
›Increased pain after cast concern
›Neurovascular compromise risk
›Padding focus
›Fifth metatarsal head and base prominences
›Malleoli padding if splint extends proximally
›Post immobilization checks
›Dorsalis pedis pulse
›Posterior tibial pulse
›Capillary refill
›Toe sensation and motor
›Reduction decision
›Indications
›Marked displacement with skin tenting
›Malrotation of fifth toe or forefoot
›Neurovascular compromise
›Cautions
›Suspected Lisfranc injury requiring specialist input
›Open fracture requiring antibiotics and tetanus pathway first when feasible
›Analgesia and anesthesia
›Analgesic framework
›Nonopioid base
›Acetaminophen PO 15 mg/kg per dose
›Maximum 1000 mg per dose
›Maximum 4000 mg per 24 hours
›NSAID option if no contraindication
›Ibuprofen PO 10 mg/kg per dose
›Maximum 600 mg per dose
›Every 6 to 8 hours as needed
›Opioid for severe pain
›Morphine PO 0.2 to 0.3 mg/kg per dose
›Maximum 15 mg per dose
›Every 4 hours as needed
›Procedural sedation if reduction required and pain uncontrolled
›Monitoring and airway readiness
›Continuous pulse oximetry
›Cardiac monitoring
›Capnography when available
›Resuscitation equipment at bedside
›Reduction technique principles
›Gentle traction and realignment
›Fifth ray traction alignment
›Countertraction at hindfoot
›Avoid repeated forceful attempts
›Escalate to orthopedics if unsuccessful
›Post reduction requirements
›Neurovascular reassessment
›Pulses and capillary refill
›Sensation in toes
›Post reduction radiographs
›Alignment confirmation
›Displacement remeasurement
Open fracture medications and timing
›Antibiotics and tetanus
›Antibiotic options
›Cefazolin IV 2 g
›Every 8 hours while awaiting definitive care
›If severe beta lactam allergy, clindamycin IV 900 mg
›Every 8 hours while awaiting definitive care
›Contamination specific escalation
›If farm or heavy contamination, add gentamicin IV 5 mg/kg
›Renal dosing adjustments required
›Tetanus prophylaxis
›If immunization unknown or incomplete, tetanus toxoid and tetanus immune globulin per protocol
›If up to date, booster per wound type timing rules
DVT prophylaxis when relevant
›Lower limb immobilization context
›Routine pharmacologic prophylaxis not universal for isolated foot fractures
›Local protocol alignment
›Shared decision in high risk patients
›High risk features
›Prior VTE
›Active cancer
›Prolonged non weight bearing
›Estrogen therapy
›Contraindications
›Active bleeding
›High bleeding risk
›Severe thrombocytopenia