Immediate life-saving interventions
›Life threats and escalation
›Trauma resuscitation pathway for high energy injury
›If open fracture suspected then antibiotics and tetanus pathway without delay
›If threatened skin then urgent orthopedics escalation
›If neurovascular deficit then immediate ortho and vascular escalation
Immobilization and Splinting
›Immobilization choice
›Knee immobilizer in extension
›Preferred for most stable patellar fractures
›Allows skin checks and swelling accommodation
›Hinged knee brace locked in extension
›Option when early supervised ROM planned
›Posterior long leg splint
›Option for severe pain or noncompliance concern
›Principles
›Knee extension position to reduce extensor mechanism tension
›Swelling phase avoidance of circumferential casting
›Post application neurovascular recheck
›Two finger tightness check at straps
›Skin protection
›Padding at malleoli and heel
›Padding at popliteal fossa strap edges
›Pressure point reassessment after ambulation trial
›Reduction considerations
›No routine reduction for isolated patellar fracture fragments
›If patellar dislocation present then reduction pathway
›Analgesia and sedation options
›Non opioid base
›Acetaminophen PO 1000 mg once then 650 to 1000 mg every 6 to 8 hours
›Ibuprofen PO 400 to 600 mg every 6 to 8 hours if no contraindication
›Opioid titration
›Morphine IV 0.05 to 0.1 mg per kg incremental dosing
›Hydromorphone IV 0.2 to 0.5 mg incremental dosing
›Regional anesthesia options
›Femoral nerve block or adductor canal block
›Ultrasound guidance preferred
›Local anesthetic selection per institutional protocol
›LAST monitoring readiness
›Procedural sedation if needed
›Airway and monitoring readiness
›Continuous pulse oximetry
›Cardiac monitor
›End tidal CO2 monitoring
›Suction and BVM at bedside
›Ketamine IV 1 mg per kg initial
›Supplemental 0.25 to 0.5 mg per kg as needed
›Propofol IV 0.5 to 1 mg per kg initial
›Supplemental 10 to 20 mg aliquots as needed
›Post reduction requirements
›Post reduction radiographs
›Neurovascular recheck
›Brace in extension
›Early ortho follow up due to osteochondral risk
Open fracture medications and timing
›Antibiotics and tetanus
›IV antibiotics as soon as possible
›Ideally within 1 hour of injury per BOAST open fracture guidance
›Local protocol selection for agent and duration
›Gustilo based approach
›Grade I and II typical coverage first generation cephalosporin pathway
›Grade III expanded gram negative coverage per protocol
›Farm or soil contamination high risk clostridial coverage per protocol
›Tetanus prophylaxis
›Vaccine status based dosing
›Tetanus immune globulin when indicated
›Wound handling
›Saline soaked sterile dressing
›Gross contamination removal only
›No deep probing in ED
›Urgent orthopedics involvement
DVT prophylaxis when relevant
›VTE risk approach
›Lower limb immobilization risk stratification
›Prior VTE history
›Active cancer
›Major trauma or surgery planned
›Pharmacologic prophylaxis
›Align with local ortho protocol
›Contraindications documentation