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