01Approach to the Critical Patient/attcp42

Immediate priorities

›Immediate priorities

›Limb threat screen

›Rapidly worsening pain

›Pain out of proportion

›Progressive paresthesia

›Cold or pale foot

›Pulseless limb

›Neurovascular baseline before immobilization

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Motor

›Ankle dorsiflexion strength

›Great toe extension strength

›Foot eversion strength

›Sensation

›Dorsum of foot sensation

›First web space sensation

›If pulseless limb, immediate reduction of gross deformity and emergent orthopedics and vascular surgery

›If compartment syndrome concern, emergent orthopedics

Open fracture pathway

›Open fracture pathway

›Skin breach near fracture site

›Active bleeding from wound

›Visible bone

›Deep puncture with contamination

›If open suspected, antibiotics and tetanus pathway before definitive splinting when feasible

02History/hx27

Mechanism and timeline

›Mechanism and timeline

›External rotation with planted foot

›Ankle syndesmosis injury concern

›Maisonneuve injury concern

›Direct lateral blow to proximal leg

›Isolated proximal fibula injury pattern

›Twisting knee injury

›LCL and posterolateral corner injury concern

›High-energy mechanism

›Multi-ligament knee injury concern

›Peroneal nerve injury risk

›Time since injury

›Ability to bear weight after injury

Symptom mapping

›Symptom mapping

›Lateral proximal leg pain

›Ankle pain

›Medial ankle pain

›Knee pain

›Numbness or tingling

›Weakness with dorsiflexion or toe extension

Risk factors and modifiers

›Risk factors and modifiers

›Anticoagulant or antiplatelet use

›Prior ipsilateral fracture or hardware

›Osteoporosis risk

›Chronic steroid use

03Physical Exam/exam39

General and regional exam

›General and regional exam

›Inspection

›Deformity

›Swelling distribution

›Ecchymosis tracking to ankle

›Skin tenting or blanching

›Open wound

›Palpation

›Fibular head and neck tenderness

›Proximal tibiofibular joint tenderness

›Lateral joint line tenderness

›Medial ankle tenderness

›Syndesmosis tenderness

›Joint above and below screen

›Knee range of motion tolerance

›Ankle range of motion tolerance

Neurovascular and nerve-specific

›Neurovascular and nerve-specific

›Vascular

›Dorsalis pedis pulse symmetry

›Posterior tibial pulse symmetry

›Capillary refill

›Common peroneal nerve function

›Ankle dorsiflexion weakness

›Great toe extension weakness

›Foot eversion weakness

›Sensory change over dorsum of foot

04Differential Diagnosis/ddx24

Injury patterns and mimics

›Injury patterns and mimics

›Isolated proximal fibula fracture

›Stable injury pattern when ankle and knee injuries excluded

›Maisonneuve fracture

›Proximal fibula fracture with unstable ankle injury

›Proximal tibiofibular joint dislocation or sprain

›Lateral knee pain with fibular head prominence

›LCL sprain or rupture

›Varus instability

›Posterolateral corner injury

›Rotational instability

›Tibial plateau fracture

›Lateral joint line tenderness with effusion

›Peroneal neuropraxia without fracture

›Compression at fibular neck

Time-critical diagnoses

›Time-critical diagnoses

›Acute compartment syndrome of leg

›Pain out of proportion

›Pain with passive stretch

›Vascular injury

›Diminished distal pulses

›Cool foot

›Open fracture

›Wound communicating with fracture

05Laboratory Tests/lt18

Minimal labs for isolated closed injury

›Minimal labs for isolated closed injury

›No routine labs for uncomplicated isolated closed fracture

›If anticoagulant use with bleeding concern

›Hemoglobin trend

›INR if warfarin

›Renal function for DOAC context

Open fracture and operative pathway

›Open fracture and operative pathway

›If open fracture suspected

›Complete blood count for baseline

›Creatinine for antibiotic dosing

›Blood type and screen if operative pathway

›If procedural sedation planned

›Point-of-care glucose if altered mental status concern

Rhabdomyolysis and crush concern

›Rhabdomyolysis and crush concern

›If prolonged entrapment or crush

›Creatine kinase

›Creatinine and electrolytes

›Urinalysis for heme positive without RBC

06Diagnostic Tests/dt47

Scoring Systems

›Scoring systems

›Gustilo-Anderson open fracture classification

›Type I

›Wound <1 cm

›Minimal contamination

›Type II

›Wound 1-10 cm

›Moderate soft tissue injury

›Type III

›Wound >10 cm or high-energy

›Extensive soft tissue damage

›Segmental fracture or farm contamination

›Salter-Harris physeal injury classification

›Type I

›Physis only

›Type II

›Physis plus metaphysis

›Type III

›Physis plus epiphysis

›Type IV

›Metaphysis plus physis plus epiphysis

›Type V

›Crush injury to physis

Radiographs

›Radiographs

›Tibia-fibula radiographs including joints above and below

›Knee included

07Disposition/dispo27

Discharge vs admission vs transfer

›Disposition decisions

›Discharge appropriate

›Closed isolated proximal fibula fracture pattern

›Normal distal pulses

›No motor deficit

›No ankle mortise instability on imaging when indicated

›Pain controlled with oral regimen

›Safe ambulation with aids

›Urgent orthopedics consultation or admission

›Open fracture

›Neurovascular deficit

›Compartment syndrome concern

›Unstable ankle injury pattern

›Suspected Maisonneuve fracture

›Suspected multi-ligament knee injury

›Transfer criteria

›Vascular injury concern

›Compartment syndrome concern

›Open fracture requiring urgent OR without local capability

Follow-up and function

›Follow-up and function

›Ortho fracture clinic

›7-10 day review for symptom and imaging reassessment if not no-follow-up pathway

›Physiotherapy

›Range of motion and gait progression when cleared

›Weight bearing status

›Weight bearing as tolerated if isolated injury and stable exam and imaging

08Treatment/t79

Immediate life-saving interventions

›Immediate life-saving interventions

›If hemorrhagic shock physiology, resuscitation per trauma protocol

›If pulseless limb, immediate reduction of gross deformity and emergent consultation

›If open fracture suspected, antibiotics and tetanus pathway

Immobilization and Splinting

›Immobilization and splinting

›Lower extremity immobilization options

›Knee immobilizer

›Use for isolated proximal fibula fracture when associated injuries excluded

›Posterior long leg splint

›Use when pain severe or concern for associated injury

›Immobilization principles

›Avoid circumferential cast in swelling phase

›Neurovascular re-check after immobilization

›Joint above and below coverage for long bone injury

›Practical conservative management option

›Knee immobilizer or bulky dressing with weight bearing as tolerated when isolated injury confirmed

Reduction

›Reduction

›Indications for reduction

›Fracture-dislocation pattern

›Threatened skin

›Neurovascular compromise

›Contraindications or caution triggers

›Suspected vascular injury requiring immediate specialist involvement

›Suspected physeal injury requiring gentle technique

›Open fracture requiring antibiotics and tetanus pathway first when feasible

›Analgesia and anesthesia

›Non-opioid analgesia

›Acetaminophen PO 1000 mg every 6-8 hours

›Maximum 3000 mg per 24 hours in older adults or liver disease risk

›Ibuprofen PO 400 mg every 6-8 hours

›Maximum 2400 mg per 24 hours

›Opioid analgesia for severe pain

›Morphine IV 0.05 mg/kg

›Titration 0.02-0.03 mg/kg every 10-15 minutes to effect

›Hydromorphone IV 0.01 mg/kg

›Titration 0.005 mg/kg every 10-15 minutes to effect

›Procedural sedation when required

›ACEP procedural sedation capnography recommendation

›Capnography adjunct for earlier hypoventilation detection

›ACEP Level B recommendation

›ACEP fasting recommendation

›Do not delay procedural sedation based on fasting time

›ACEP Level B recommendation

›Medication options

›Ketamine IV 1 mg/kg

›Supplemental 0.25-0.5 mg/kg every 5-10 minutes

›Propofol IV 0.5-1 mg/kg

›Supplemental 0.25-0.5 mg/kg every 2-3 minutes

›Post-reduction requirements

›Immediate neurovascular re-check

›Post-reduction imaging

›Immobilization in position of stability

›Failed reduction pathway

›Persistent neurovascular deficit triggers immediate escalation

›Irreducible deformity triggers urgent orthopedics

Open fracture medications and timing

›Open fracture medications and timing

›Antibiotics

›Cefazolin IV 2 g

›Repeat every 8 hours until definitive management per local protocol

›If severe beta-lactam allergy

›Clindamycin IV 900 mg

›Repeat every 8 hours per local protocol

›If farm or heavy contamination concern

›Add gram-negative coverage per local protocol

›Tetanus prophylaxis

›Td or Tdap if immunization incomplete or unknown

›Tetanus immune globulin if high-risk wound and unimmunized

›Wound care

›Sterile moist dressing

›Gross debris removal without deep probing

DVT prophylaxis when relevant

›DVT prophylaxis when relevant

›Lower limb immobilisation VTE risk assessment

›NICE Quality Standard recommendation for VTE risk assessment at discharge with lower limb immobilisation

›Shared decision-making on pharmacologic prophylaxis when risk outweighs bleeding risk

›Definition relevant to ED discharge

›Immobilisation includes prevention of normal weight-bearing or normal limb use

›If pharmacologic prophylaxis indicated by local protocol

›Low molecular weight heparin dosing per local protocol

›Renal dosing adjustment for reduced creatinine clearance

09Special Populations/sp29

Pregnancy

›Pregnancy

›Imaging considerations

›Shielding when feasible

›Radiation minimization with clinically appropriate modalities

›Analgesia considerations

›Acetaminophen preferred first line

›NSAID avoidance in later pregnancy per local obstetric guidance

›VTE risk considerations

›Increased baseline VTE risk

›Lower threshold for risk assessment with immobilization

Geriatric

›Geriatric

›Fragility context

›Low-energy mechanism possible

›Osteoporosis evaluation pathway

›Medication safety

›Opioid delirium risk

›NSAID renal and GI risk

›Mobility and falls

›Higher threshold for admission if unsafe ambulation

Pediatrics

›Pediatrics

›Growth plate injury risk

›Salter-Harris consideration when pain near physis

›Gentle immobilization and early ortho follow-up

›Non-accidental trauma consideration

›Inconsistent history

10Background/b24

Epidemiology

›Epidemiology

›Typical healing time

›Approximately 6 weeks for proximal fibula fracture healing in uncomplicated cases

›Lower limb immobilisation and VTE risk context

›Temporary lower limb immobilisation after injury associated with measurable DVT risk in published quality improvement literature

Pathophysiology

›Pathophysiology

›Fibula load-bearing contribution

›Fibula bears a minority of body weight load

›Injury pattern mapping

›External rotation force transmission through interosseous membrane

›Proximal fibula fracture as part of Maisonneuve injury

›Nerve vulnerability

›Common peroneal nerve proximity at fibular neck

›Traumatic causes include proximal fibula fracture

Therapeutic Considerations

›Therapeutic considerations

›Conservative management rationale

›Stable isolated proximal fibula fractures typically managed nonoperatively

›Immobilization choice rationale

›Hinged knee brace or knee immobilizer for comfort and protection when stable

›Weight bearing rationale

›Weight bearing as tolerated when isolated injury and associated injuries excluded

›Critical miss prevention rationale

›Mandatory ankle evaluation when mechanism suggests syndesmosis injury

›Mandatory peroneal nerve exam documentation

11Patient Discharge Instructions/pdi33

copy discharge instructions

›copy discharge instructions

›Diagnosis

›Proximal fibula fracture

›Immobilization care

›Keep splint or brace dry

›Do not insert objects into splint

›Loosen wrap if increasing tightness

›Swelling control

›Elevation above heart when resting

›Ice 15-20 minutes at a time with skin protection

›Activity

›Weight bearing as tolerated only if instructed

›Crutches if limping or pain with weight bearing

›No running or jumping until cleared

›Pain plan

›Acetaminophen as directed

›Ibuprofen as directed if safe for you

›Opioid only if prescribed

›Return to ED now

›Increasing pain not controlled with medication

›New numbness or tingling

›New weakness lifting foot or toes

›Toes becoming pale, blue, or cold

›Increasing tightness in calf or severe pain with toe movement

›Fever or wound drainage

›Follow-up

›Orthopedics or fracture clinic within 7-10 days unless given a no-follow-up pathway

12References/r28

Evidence-based sources

›Evidence-based sources

›ACI NSW Emergency Care Institute clinical tool for proximal fibula fractures

›Isolated injuries managed with hinged knee brace and ortho follow-up

›Orthopedics consultation for associated knee, ankle, or neurovascular injury

›Orthopedic Teaching Northwestern ED management

›Isolated proximal fibula fractures managed conservatively

›Knee immobilizer or bulky dressing with weight bearing as tolerated when isolated injury confirmed

›Radiopaedia Maisonneuve fracture reference

›Proximal fibula fracture with unstable ankle injury pattern

›CoreEM Maisonneuve fractures review

›Proximal fibula fracture with distal tibiofibular syndesmosis injury and ankle mortise disruption

›StatPearls Peroneal Nerve Injury

›Proximal fibula fracture as cause of common peroneal nerve injury

›NICE NG89 Venous thromboembolism risk reduction

›VTE and bleeding risk assessment framework

›NICE Quality Standard QS201 statement on lower limb immobilisation

›VTE risk assessment for people discharged with lower limb immobilisation

›Horner 2019 thromboprophylaxis in lower limb immobilisation review

›Definition of lower limb immobilisation relevant to VTE risk assessment

›ACEP Clinical Policy Procedural Sedation and Analgesia in the ED 2014

›Capnography adjunct recommendation

›ACEP Level B recommendation

›Fasting time not a reason to delay sedation

›ACEP Level B recommendation

›ICD-10-CM S82.831A category for other fracture of upper and lower end of fibula

›Laterality and encounter character requirements

›SNOMED CT 59639009 Closed fracture of upper end of fibula

Evidence & Review

Evidence & Review