Immediate life-saving interventions
›Limb threat actions
›If pulseless then immediate splint loosening and reassessment
›If persistent pulseless then immediate vascular and ortho escalation
›If hemodynamic instability then trauma resuscitation pathway
›If open fracture then antibiotics and tetanus pathway first when feasible
›Cover wound with sterile dressing
›Urgent orthopedics for operative management
Immobilization and Splinting
›Splint and immobilization choice
›Posterior short leg splint
›Add stirrup for rotational control
›Neutral ankle position
›Walking boot only when clearly stable and low swelling
›Stress fracture follow up pathway
›Avoid if significant swelling or unstable pattern
›Immobilization principles
›Non weight bearing for suspected navicular fracture until specialist review
›Crutches or walker training
›Knee scooter option if safe
›Swelling phase casting avoidance
›Splint preferred initially
›Cast after swelling decreases
›Recheck after splint
›Pulses
›Cap refill
›Sensory and motor
›Reduction indications
›Fracture dislocation
›Talonavicular subluxation
›Gross midfoot deformity
›Threatened skin
›Blanching
›Tenting
›Neurovascular compromise
›Diminished pulses
›Progressive numbness
›Analgesia and anesthesia
›Multimodal analgesia baseline
›Acetaminophen PO 1000 mg
›Ibuprofen PO 400 mg
›Opioid for severe pain
›Oxycodone PO 5 mg
›Reassess effect at 30 to 60 minutes
›Procedural sedation when reduction required
›Ketamine IV 1 mg per kg
›Additional ketamine IV 0.5 mg per kg if needed
›Repeat every 5 to 10 minutes to effect
›Maximum total dose per local protocol
›Propofol IV 0.5 mg per kg
›Additional propofol IV 0.25 mg per kg
›Repeat every 2 to 3 minutes to effect
›Airway readiness and continuous monitoring
›Technique principles
›Gentle traction and countertraction
›Restore length
›Avoid repeated forceful attempts
›Reverse mechanism when clear
›Correct dislocation vector
›Stop if resistance suggests interposed tissue
›Post reduction requirements
›Immediate neurovascular reassessment
›Pulses and cap refill
›Sensory and motor
›Post reduction imaging
›Confirm talonavicular congruity
›Confirm navicular alignment
›Immobilization in stable position
›Posterior short leg plus stirrup
›Strict non weight bearing
›Failed reduction pathway
›Persistent deformity then urgent orthopedics
›Consider interposition
›Consider urgent OR reduction
›Worsening pain and swelling then compartment syndrome pathway
›Loosen splint
›Escalate immediately
Open fracture medications and timing
›Antibiotics
›Gustilo I and II coverage
›Cefazolin IV 2 g
›Repeat dosing per local protocol
›Gustilo III or heavy contamination coverage
›Cefazolin IV 2 g
›Add gentamicin dosing per local protocol
›Severe beta lactam allergy
›Clindamycin IV per local protocol
›Add gram negative coverage when indicated
›Tetanus prophylaxis
›Clean minor wound
›Vaccine booster if not up to date
›Dirty wound or open fracture
›Vaccine booster if not up to date
›Tetanus immune globulin when indicated
›Dressing and irrigation principles
›Sterile moist dressing
›Avoid high pressure irrigation in ED if OR imminent
›Avoid contamination spread
DVT prophylaxis when relevant
›Risk assessment
›Lower limb immobilization
›Prolonged non weight bearing
›Prior VTE history
›High risk comorbidities
›Active cancer
›Thrombophilia
›Plan per local protocol
›If high risk then pharmacologic prophylaxis discussion and documentation
›If low risk then early mobilization of unaffected limb and hydration