Immediate life-saving interventions
›Limb threat actions
›If pulseless hand, immediate reduction attempt if deformity suggests dislocation component
›Immediate orthopedic and vascular escalation if no pulse return
›If open fracture, cover with sterile moist dressing
›Antibiotics pathway as early as possible
›If compartment syndrome concern, immediate escalation for fasciotomy evaluation
›Constriction relief
›Ring removal if hand swelling
Immobilization and Splinting
›Splint choice
›Posterior long arm splint
›Elbow at 45 to 90 degrees flexion based on comfort and swelling
›Forearm neutral
›Sling support
›Shoulder offloading
›Immobilization principles
›Avoid circumferential cast in acute swelling phase
›Padding over olecranon and ulnar styloid
›Two finger tightness check
›Neurovascular reassessment after splint
›Post application checks
›Pain trend
›Finger motion
›Sensation
›Capillary refill
›Radial pulse
›Ulnar pulse
›Indications for urgent realignment
›Threatened skin over olecranon
›Fracture dislocation component
›Neurovascular compromise
›Analgesia and anesthesia options
›Non opioid analgesia
›Acetaminophen PO 1000 mg
›Maximum 4000 mg per 24 hours
›Ibuprofen PO 400 mg
›Typical maximum 2400 mg per 24 hours
›Opioid options
›Hydromorphone IV 0.2 mg to 0.5 mg
›Titration every 10 minutes to comfort
›Respiratory depression monitoring
›Regional anesthesia options
›Brachial plexus block support by trained clinician
›Ultrasound guidance when available
›Local anesthetic systemic toxicity monitoring
›If neurologic symptoms or arrhythmia, initiate lipid emulsion rescue per protocol
›Procedural sedation pathway when needed
›Monitoring and readiness
›Continuous pulse oximetry
›Continuous ECG
›Capnography when available
›Suction ready
›Sedation options
›Ketamine IV 1 mg/kg
›Additional 0.5 mg/kg as needed
›Emergence reaction mitigation plan
›Propofol IV 0.5 mg/kg
›Additional 0.25 mg/kg to 0.5 mg/kg as needed
›Hypotension monitoring
›Technique principles
›Gentle sustained traction and countertraction
›Avoid repeated forceful attempts
›Alignment to reduce skin tension when tenting present
›Post reduction requirements
›Immediate neurovascular recheck
›Post reduction radiographs
›Posterior long arm splint reapplication and molding
›Failed reduction pathway
›Persistent deformity with instability concern triggers urgent orthopedics
›Persistent neurovascular deficit triggers immediate escalation
Open fracture medications and timing
›Antibiotics
›Cefazolin IV 2 g
›Repeat dosing per operative timing and local protocol
›Severe cephalosporin allergy
›Clindamycin IV 900 mg
›Gross contamination or farm injury concern
›Add gentamicin IV 5 mg/kg per protocol
›Tetanus prophylaxis
›Unknown or incomplete immunization
›Tdap
›Tetanus immune globulin per protocol
›Up to date immunization
›Tdap if due by schedule
›Wound care
›Sterile moist dressing
›No aggressive ED debridement
›Irrigation when heavily contaminated if it does not delay antibiotics and transfer