Immediate life-saving interventions
›Limb ischemia actions
›If pulseless or cool foot, immediate reduction of gross deformity if present
›If persistent deficit after alignment, emergent vascular surgery activation
›If ABI < 0.9, CT angiography pathway
›Compartment syndrome actions
›If escalating pain with passive stretch, emergent orthopedic escalation
›Avoid tight circumferential dressings
›Open fracture actions
›Sterile saline soaked dressing
›Antibiotics as early as possible
›Tetanus prophylaxis pathway
Immobilization and Splinting
›Immobilization choice
›Knee immobilizer for stable minimally displaced injury
›Posterior long leg splint for significant pain or instability
›Hinged knee brace if directed and swelling manageable
›Immobilization principles
›Neutral alignment
›Avoid excessive flexion with swelling
›Elevation above heart level when feasible
›Ice intermittently
›Neurovascular recheck after splinting
›Mobility support
›Crutches or walker training
›Strict non weight bearing instruction
›Reduction indications
›Fracture dislocation pattern
›Neurovascular compromise
›Gross malalignment
›Threatened skin tension
›Analgesia and anesthesia
›Multimodal baseline
›Acetaminophen 1000 mg PO once
›Ibuprofen 400 mg PO once if no contraindications
›Opioid titration for severe pain
›Fentanyl IV 25 to 50 microg increments
›Reassess every 5 minutes
›Procedural sedation if reduction needed
›Monitoring and airway readiness
›Continuous pulse oximetry
›Cardiac monitoring
›End tidal CO2 if available
›Suction and BVM at bedside
›Sedation options
›Ketamine IV 1 mg/kg
›If inadequate sedation, ketamine IV 0.5 mg/kg repeat
›Reassess every 5 minutes
›Maximum cumulative dose per local protocol
›Propofol IV 0.5 mg/kg initial
›Propofol IV 0.25 to 0.5 mg/kg repeats
›Reassess every 1 to 2 minutes
›Hypotension risk escalation
›Reduction technique principles
›Long axis traction and countertraction
›Gentle correction of varus or valgus malalignment
›Avoid repeated forceful attempts
›Post reduction requirements
›Immediate neurovascular recheck
›Post reduction radiographs
›Immobilization in stable alignment
Open fracture medications and timing
›Antibiotics by contamination risk
›Gustilo I to II suspected
›Cefazolin IV 2 g
›Repeat dosing per operative timing and local protocol
›Gustilo III suspected or gross contamination
›Cefazolin IV 2 g
›Gentamicin IV 5 mg/kg
›Severe beta lactam allergy
›Clindamycin IV 900 mg
›Add gram negative coverage per local protocol if high grade
›Farm or soil contamination concern
›Add anaerobe coverage per local protocol
›Tetanus prophylaxis
›Unknown or incomplete immunization
›Tetanus toxoid containing vaccine
›Tetanus immune globulin for dirty wounds per protocol
›Up to date immunization
›Booster based on wound and timing
DVT prophylaxis when relevant
›Elevated risk contexts
›Lower limb immobilization with non weight bearing
›Operative fixation planned
›Prior VTE history
›Active malignancy
›Hormonal therapy use
›Pharmacologic options typical regimens
›Enoxaparin 40 mg SC daily if no contraindications
›If renal impairment, dosing adjustment per creatinine clearance
›Contraindications
›Active bleeding
›High risk intracranial injury
›Pending urgent surgery decision without plan
›Documentation
›Risk benefit rationale
›Follow up plan for continuation or discontinuation