Immediate life-saving interventions
› Critical actions
› If pulseless limb, immediate orthopedic and vascular escalation
› If hard signs of vascular injury, bypass delays for definitive care
› If open fracture, antibiotics and tetanus pathway before prolonged imaging when feasible
› If hemorrhagic shock, transfusion pathway per local massive transfusion protocol
› Analgesia early
› Multimodal pain control plan
› Acetaminophen PO 1000 mg q6h
› Ibuprofen PO 400 mg q6-8h if no contraindication
› Opioid for severe pain
› Hydromorphone IV 0.2-0.5 mg q10-15 min to effect
› Morphine IV 2-4 mg q10-15 min to effect
Immobilization and Splinting
› Immobilization choice
› Knee immobilizer
› Stable nondisplaced pattern
› Minimal swelling concern
› Posterior long leg splint
› Unstable pattern
› Significant swelling
› Posterior long leg plus stirrup
› Additional rotational control need
› Immobilization principles
› Knee near extension for comfort
› Avoid circumferential cast in swelling phase
› Re-check neurovascular status after splinting
› Reduction indications
› Neurovascular compromise with deformity
› Threatened skin from sharp fragment tenting
› Fracture-dislocation
› Analgesia and anesthesia options
› Regional anesthesia
› Femoral nerve block or fascia iliaca block
› Ropivacaine 0.2% 20-30 mL
› Max dose per weight and local protocol
› Procedural sedation when needed
› Monitoring and airway readiness
› Cardiac monitor
› Continuous pulse oximetry
› Capnography
› Suction and BVM at bedside
› Ketamine IV
› 0.5-1 mg/kg slow IV for dissociation
› Additional 0.25-0.5 mg/kg PRN
› Propofol IV
› 0.5-1 mg/kg initial bolus
› 10-20 mg boluses q1-2 min to effect
› Technique principles
› Gentle longitudinal traction and countertraction
› Deformity exaggeration to disengage when applicable
› Reverse mechanism when clear
› Avoid repeated forceful attempts
› Post-reduction requirements
› Immediate neurovascular re-check
› Post-reduction imaging
› Immobilization in stable position
› Failed reduction pathway
› Persistent neurovascular deficit triggers emergent escalation
› Irreducible deformity triggers urgent orthopedics
Open fracture medications and timing
› Antibiotics and wound coverage
› Immediate sterile dressing and gross contamination control
› Cefazolin IV 2 g q8h for type I-II suspicion
› If severe beta-lactam allergy
› Clindamycin IV 900 mg q8h
› Type III suspicion or heavy contamination
› Add gentamicin IV 5 mg/kg daily
› Farm or fecal contamination concern
› Add metronidazole IV 500 mg q8h
› Tetanus prophylaxis
› Unknown or incomplete immunization
› Tetanus toxoid vaccine
› Tetanus immune globulin per local protocol
DVT prophylaxis when relevant
› VTE prevention planning
› High risk features
› Lower limb immobilization
› Operative fixation expected
› Prior VTE
› Active cancer
› Pharmacologic prophylaxis inpatient per local protocol
› Contraindications documentation
› Active bleeding
› Severe thrombocytopenia
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