›Threatened skin tenting
›Gross deformity with severe pain
›Caution triggers
›Suspected vascular injury and knee dislocation pattern
›Open fracture with contamination requiring antibiotics first when feasible
›Analgesia and anesthesia
›Multimodal analgesia base
›Acetaminophen 1000 mg PO q6h maximum 4000 mg per 24h
›Ibuprofen 400 mg PO q6h if no renal or bleeding contraindication
›Opioid titration for severe pain
›Fentanyl IV 25 to 50 micrograms q5 min to effect
›Morphine IV 2 to 4 mg q5 to 10 min to effect
›Procedural sedation when required
›Monitoring and readiness standards
›Continuous ECG and pulse oximetry
›Capnography when available
›Airway equipment and reversal agents immediately available
›Sedation agents examples
›Ketamine IV 1 mg per kg initial
›Additional 0.25 to 0.5 mg per kg q5 to 10 min as needed
›Propofol IV 0.5 mg per kg initial
›Additional 0.25 mg per kg q1 to 3 min as needed
›Technique principles
›Longitudinal traction and countertraction
›Gentle correction of angulation
›Avoid repeated forceful attempts
›Post-reduction requirements
›Repeat neurovascular exam documentation
›Post-reduction radiographs
›Immobilization in most stable position
Open fracture medications and timing
›Open fracture medication pathway
›Antibiotics timing
›Initiate IV antibiotics as early as possible after recognition
›Document time of first dose
›Antibiotic choices
›Cefazolin IV 2 g q8h for most open fractures
›Add gentamicin IV 5 mg per kg daily for severe soft tissue injury per local protocol
›Add metronidazole IV 500 mg q8h for farm or fecal contamination risk
›Clindamycin IV 900 mg q8h for severe beta-lactam allergy
›Tetanus prophylaxis
›Tdap if immunization unknown or not up to date
›Tetanus immune globulin if dirty wound and incomplete immunization
›Wound handling
›Cover with sterile saline dressing
›Avoid aggressive ED irrigation if OR imminent and contamination not gross
DVT prophylaxis when relevant
›VTE prevention planning
›High risk features
›Lower limb immobilization
›Major trauma or planned surgery
›Prior VTE or active cancer
›Pharmacologic prophylaxis coordination
›Follow local trauma or ortho protocol for LMWH timing
›Hold if active bleeding or pending emergent surgery per surgeon request
›Mechanical prophylaxis
›Intermittent pneumatic compression when inpatient and no contraindication