Immediate life-saving interventions
›Limb-threatening ischemia actions
›Constriction removal
›Rings and bracelets
›Tight clothing or dressings
›If pulseless hand with deformity, immediate reduction attempt
›Traction-countertraction technique
›Recheck pulses immediately after
›If persistent ischemia after reduction, immediate vascular pathway
›CTA if available and no delay
›Transfer if vascular service not available
›Hemorrhage and wound actions for open fracture
›Direct pressure for bleeding
›Avoid circumferential tourniquet unless life-threatening hemorrhage
›Document tourniquet time if used
›Sterile dressing
›Saline-moistened gauze
›Cover exposed bone
Immobilization and Splinting
›Splint selection
›Sugar tong splint
›Most distal radius and distal ulna fractures
›Forearm rotation control
›Posterior long arm splint
›Proximal forearm fractures
›Elbow immobilization for Monteggia patterns
›Volar wrist splint
›Selected nondisplaced distal radius fractures
›Avoid when rotation control needed
›Coaptation splint
›Select proximal ulna patterns
›When long arm immobilization required
›Immobilization principles
›Joint above and below for diaphyseal fractures
›Elbow immobilization
›Wrist immobilization
›Swelling-phase casting caution
›Avoid circumferential cast in first 48 to 72 hours if swelling expected
›Bivalve cast if cast required and swelling risk high
›Positioning
›Elbow 90 degrees when long arm splint used unless contraindicated
›Forearm neutral to slight supination when DRUJ stability desired
›Post-splint checks
›Pain reassessment
›Escalation if worsening pain
›Compartment syndrome warning reinforcement
›Neurovascular reassessment
›Pulses and cap refill
›Median, ulnar, radial motor and sensation
›Indications for reduction
›Neurovascular compromise
›Absent pulse with deformity
›Progressive sensory loss
›Threatened skin
›Tenting or blanching
›Impending open fracture
›Fracture-dislocation patterns
›Monteggia radial head dislocation
›Galeazzi DRUJ disruption with instability
›Analgesia and anesthesia options
›Non-opioid baseline
›Acetaminophen PO 1000 mg
›Ibuprofen PO 400 to 600 mg if no contraindication
›Opioid titration
›Hydromorphone IV 0.2 to 0.5 mg
›Fentanyl IV 25 to 50 mcg
›Regional and local options
›Hematoma block for distal radius fractures
›Lidocaine 1% 10 mL maximum
›Aspirate before injection to avoid intravascular injection
›Ultrasound-guided forearm nerve block when appropriate expertise
›Median nerve block
›Ulnar nerve block
›Procedural sedation pathway when needed
›Monitoring and airway readiness
›Continuous ECG and pulse oximetry
›Capnography when available
›Suction and BVM at bedside
›Medication options
›Ketamine IV 1 mg/kg
›Additional 0.5 mg/kg every 5 to 10 minutes if needed
›Emergence reaction mitigation with quiet environment
›Propofol IV 0.5 to 1 mg/kg
›Additional 0.25 to 0.5 mg/kg every 2 to 3 minutes
›Hypotension and apnea risk counseling
›Etomidate IV 0.1 to 0.15 mg/kg
›Myoclonus risk
›Limited analgesia pairing need
›Reduction principles
›Traction and countertraction
›Restore length
›Reduce soft tissue interposition
›Deformity exaggeration when needed
›Disengage fragments
›Avoid repeated forceful attempts
›Reverse mechanism logic when clear
›Correct apex angulation
›Correct rotational deformity
›Post-reduction requirements
›Immediate neurovascular recheck
›Document motor and sensation change
›Document pulse and cap refill change
›Post-reduction imaging
›Forearm AP and lateral
›Joint congruity confirmation at elbow and wrist
›Immobilization in stable position
›Sugar tong for distal injuries
›Long arm splint for unstable shaft or proximal patterns
›Failed reduction pathway
›Persistent neurovascular deficit
›Immediate orthopedics escalation
›Vascular escalation if ischemia persists
›Irreducible deformity
›Urgent orthopedics
›Avoid multiple repeated attempts
Open fracture medications and timing
›Antibiotic regimens
›Gustilo Type I to II
›Cefazolin IV 2 g every 8 hours
›Clindamycin IV 900 mg every 8 hours for severe beta-lactam allergy
›Gustilo Type III
›Cefazolin IV 2 g every 8 hours
›Gentamicin IV 5 mg/kg once daily dosing option
›Farm or fecal contamination
›Add metronidazole IV 500 mg every 8 hours
›Alternative anaerobe coverage per local protocol
›Timing targets
›First dose as early as possible
›Document antibiotic time
›Tetanus prophylaxis logic
›Clean minor wound
›Td or Tdap if last dose 10 years or more
›No TIG if immunized
›Dirty wound or open fracture
›Td or Tdap if last dose 5 years or more
›TIG if unknown or incomplete immunization
›Wound handling principles
›Gross debris removal without deep probing
›Gentle saline irrigation
›Avoid high-pressure irrigation in ED when OR planned
›Sterile dressing maintenance
›Saline-moistened gauze
›Keep splint material away from open wound
DVT prophylaxis when relevant
›Upper extremity fracture default
›Routine pharmacologic prophylaxis not typical for isolated ambulatory upper extremity immobilization
›Individual risk assessment
›Align with local protocol
›Higher risk scenarios
›Admission with reduced mobility or polytrauma
›LMWH per institutional protocol if no contraindication
›Mechanical prophylaxis when anticoagulation contraindicated
›Contraindications
›Active bleeding
›Planned urgent surgery timing considerations