Enoxaparin SC 30 mg every 12 hours in trauma protocols
Dose adjustment per renal function and weight
Contraindications
Active bleeding
Severe traumatic brain injury with evolving hemorrhage
Mechanical prophylaxis
Intermittent pneumatic compression when anticoagulation held
Early mobilization when feasible
Special Populations
Pregnancy
Maternal and fetal priorities
Maternal stabilization first
Standard trauma resuscitation principles
Left lateral uterine displacement in later gestation
Imaging considerations
Radiographs when clinically indicated
Shielding when feasible without compromising imaging
Analgesia considerations
Acetaminophen preferred baseline
Opioids when needed with monitoring
Obstetric involvement triggers
Viable gestation with trauma
Abdominal pain or vaginal bleeding
Geriatric
Frailty and comorbidity considerations
Lower energy mechanisms possible
Fall from standing with pathologic bone
Osteoporosis contribution
Medication sensitivity
Opioid delirium risk
Renal dosing for anticoagulation
Higher admission threshold
Baseline mobility impairment
Social support limitations
Pediatrics
Growth and safety considerations
Physeal injury risk
Distal femur physeal fracture consideration
Salter Harris patterns for adjacent injuries
Non accidental trauma consideration
Inconsistent mechanism
Developmental mismatch
Weight based analgesia
Fentanyl IV 1 mcg/kg increments
Ketamine IV 0.1 to 0.3 mg/kg for analgesia
Immobilization considerations
Age appropriate splinting
Spica casting pathways for certain patterns
Background
Epidemiology
Population patterns
Mechanism distribution
High energy trauma common in younger patients
Low energy fragility or pathologic fractures in older patients
Hemorrhage burden
Femoral shaft fracture associated with major blood loss
Higher transfusion risk in polytrauma
Associated injury frequency
Ipsilateral femoral neck fracture association
Knee ligament injury association
Pathophysiology
Injury mechanics
Force vectors
Bending leading to transverse fracture
Torsion leading to spiral fracture
Combined forces leading to comminution
Bleeding mechanisms
Medullary canal bleeding
Surrounding muscle compartment bleeding
Neurovascular risk
Femoral artery proximity
Sciatic nerve vulnerability with high energy trauma
Therapeutic Considerations
Treatment rationale
Early stabilization benefits
Pain reduction
Bleeding reduction
Improved transport safety
Definitive fixation principles
Intramedullary nailing standard for most adult diaphyseal fractures
External fixation as damage control in unstable polytrauma
Evidence and guideline framing
ATLS prioritization of hemorrhage control and limb stabilization
Procedural sedation safety principles aligned with ACEP guidance level B for ED sedation monitoring
Patient Discharge Instructions
Copy discharge instructions
Discharge eligibility context
Femoral shaft fracture usually requires admission and operative management
Discharge rare and only in exceptional specialist directed pathways
If discharged under specialist plan
Immobilization care
Keep splint clean and dry
Elevation above heart level when resting
Pain plan
Acetaminophen as baseline
NSAID use only if permitted by surgeon
Opioid only as prescribed
Activity restriction
Non weight bearing until cleared
No driving
Return to ED now
Increasing pain not controlled by medication
New numbness or weakness in foot
Pale or cool foot
Increasing tightness or swelling of thigh
Fever or wound drainage
Follow up
Orthopedics appointment timing per plan
Imaging follow up if instructed
References
Clinical guidelines and core sources
Trauma and orthopedic references
ATLS principles for initial management of long bone fractures and hemorrhage control
AAOS guidance on fracture care and perioperative considerations
BOAST guidance for open fracture management principles and timing
NICE guidance for major trauma pathways and imaging principles
Evidence based sources
Sedation and procedural references
ACEP clinical policy and consensus guidance for ED procedural sedation monitoring and safety
Evidence supporting early antibiotics for open fractures and infection reduction
Evidence supporting traction splinting for pain control and hemorrhage mitigation in appropriate femoral shaft fractures
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