Immediate life-saving interventions
›Time critical threats
›Fracture-dislocation with threatened skin
›Immediate reduction in ED
›Splint after reduction
›Persistent pulseless foot after reduction
›Immediate vascular surgery escalation
›Emergent transfer if no vascular coverage
›Open fracture pathway
›Sterile saline-moistened dressing
›Antibiotics within 1 hour target
›Tetanus prophylaxis decision pathway
Immobilization and Splinting
›Splint selection hindfoot and ankle
›Posterior short leg plus stirrup
›Most talus fractures initial immobilization
›Avoid circumferential cast during swelling phase
›Posterior long leg
›Unstable fracture-dislocation
›Significant subtalar instability
›Position targets
›Neutral ankle position
›Slight plantarflexion when posterior process pain prominent and tolerated
›Post-splint checks
›Two-finger tightness check
›Neurovascular reassessment documented
›Indications
›Neurovascular compromise
›Threatened skin or tenting
›Tibiotalar or subtalar dislocation
›Analgesia and anesthesia options
›Non-opioid base
›Acetaminophen oral 1000 mg once
›Maximum 3000 mg per day typical adult limit when no liver disease
›Ibuprofen oral 600 mg once
›Avoid in significant renal disease or high bleeding risk
›Opioid titration
›Fentanyl IV 0.5 to 1 mcg per kg
›Repeat 0.5 mcg per kg every 5 minutes to effect
›Continuous pulse oximetry and capnography when available
›Procedural sedation
›Ketamine IV 1 mg per kg
›Additional 0.5 mg per kg every 5 to 10 minutes as needed
›Airway equipment and trained staff present
›Technique principles
›Longitudinal traction with countertraction
›Deformity exaggeration to disengage when locked
›Reverse mechanism based on deformity direction
›Gentle sustained force over seconds to minutes
›Post-reduction requirements
›Immediate neurovascular re-check
›Post-reduction radiographs
›CT after reduction for talar neck body fractures
›Failed reduction pathway
›Irreducible dislocation
›Emergent orthopedics
›Emergent transfer if no capability
›Persistent neurovascular deficit
›Vascular surgery escalation
Open fracture medications and timing
›Antibiotics selection
›Gustilo type I or II
›Cefazolin IV 2 g every 8 hours
›Start as soon as possible
›Typical duration 24 hours after operative debridement
›Gustilo type III or gross contamination
›Cefazolin IV 2 g every 8 hours
›Plus gentamicin IV 5 mg per kg daily
›Renal dosing adjustment when indicated
›Farm soil or fecal contamination concern
›Add metronidazole IV 500 mg every 8 hours
›Severe beta-lactam allergy
›Clindamycin IV 900 mg every 8 hours
›Add gentamicin IV 5 mg per kg daily for type III
›Tetanus prophylaxis
›Unknown or incomplete immunization
›Tetanus immune globulin per local protocol
›Tetanus toxoid booster
›Up-to-date immunization
›Booster if high-risk wound and last dose over 5 years
DVT prophylaxis when relevant
›Risk assessment lower limb immobilization
›Non-weight bearing more than 2 weeks
›Prior venous thromboembolism
›Active malignancy
›Estrogen therapy
›Prophylaxis alignment with local protocol
›LMWH when high risk and low bleeding risk
›Contraindications
›Active bleeding
›High bleeding risk surgery pending
›Documentation elements
›Risk factors listed
›Plan and follow-up responsibility