Immediate life-saving interventions
›Limb and life threats
›If shock, hemorrhage protocol and trauma activation
›Balanced transfusion per local MTP
›TXA within trauma protocol if eligible
›If threatened perfusion, immediate realignment and splint
›Recheck pulses after alignment
›If no improvement, emergent vascular escalation
›If open fracture suspected, antibiotics and tetanus before delays
›Dressing and splint after antibiotics when feasible
Immobilization and Splinting
›Immobilization approach
›Splint selection
›Posterior long leg splint
›Posterior long leg plus stirrup for added rotational control
›Knee immobilizer only as adjunct when swelling prohibits full splinting
›Position and principles
›Knee in slight flexion per comfort and stability
›Ankle at neutral dorsiflexion
›Joint above and below immobilized
›Application safety
›Extra padding over malleoli and heel
›Avoid circumferential cast in acute swelling phase
›Two finger tightness check
›Post splint reassessment
›Pain trend
›Motor and sensory exam repeated
›Distal pulses and cap refill repeated
›Realignment and reduction framework
›Indications for reduction attempt
›Neurovascular compromise
›Severe angulation or shortening
›Threatened skin tenting
›Fracture dislocation pattern at ankle or knee
›Caution triggers
›Suspected vascular injury
›Immediate specialist involvement prioritized
›Open fracture
›Antibiotics and tetanus pathway first when feasible
›Analgesia and anesthesia options
›Multimodal analgesia
›Acetaminophen PO 1000 mg once
›Ibuprofen PO 600 mg once if no contraindication
›Ketorolac IV 15 mg once if no contraindication
›Opioid titration
›Fentanyl IV 25 to 50 micrograms
›Repeat every 5 minutes to comfort and safety
›Hold if hypoventilation or sedation
›Hydromorphone IV 0.2 to 0.5 mg
›Repeat every 10 to 15 minutes to effect
›Caution in opioid naive and older adults
›Procedural sedation when needed
›ASA assessment and airway risk
›If high risk airway, anesthesia support per local pathway
›Ketamine IV 1 mg per kg
›Additional 0.25 to 0.5 mg per kg as needed
›Continuous monitoring with capnography
›Propofol IV 0.5 to 1 mg per kg
›Additional 0.25 to 0.5 mg per kg as needed
›Hypotension risk mitigation with fluids and dose reduction
›Etomidate IV 0.1 to 0.2 mg per kg
›Myoclonus and adrenal suppression considerations
›Technique principles
›Traction and countertraction
›Gentle exaggeration of deformity when needed to disengage
›Reverse mechanism when rotational component suspected
›Sustained alignment hold while splint molded
›Avoid repeated forceful attempts
›Post reduction requirements
›Neurovascular status documented immediately
›Post reduction radiographs
›Immobilization in position of stability
›Failed reduction pathway
›Persistent neurovascular deficit triggers emergent ortho escalation
›Irreducible deformity triggers urgent operative pathway
›Worsening pain and tense compartments triggers compartment syndrome escalation
Open fracture medications and timing
›Antibiotics and tetanus
›Antibiotic timing target
›As early as possible after recognition
›Do not delay for imaging if open fracture evident
›Antibiotic selection by Gustilo category
›Type I or II coverage
›Cefazolin IV 2 g every 8 hours
›Weight 120 kg or more cefazolin IV 3 g every 8 hours
›Severe beta lactam allergy clindamycin IV 900 mg every 8 hours
›Type III coverage
›Ceftriaxone IV 2 g daily
›Add gentamicin IV 5 mg per kg daily per local protocol if high contamination
›Severe beta lactam allergy clindamycin IV 900 mg every 8 hours plus ciprofloxacin IV 400 mg every 12 hours
›Farm or fecal contamination concern
›Add metronidazole IV 500 mg every 8 hours
›Alternative clindamycin already provides anaerobe coverage
›Freshwater exposure
›Add fluoroquinolone per local protocol
›Saltwater exposure
›Add doxycycline 100 mg PO or IV every 12 hours plus ceftazidime per local protocol
›Tetanus prophylaxis
›Clean minor wound with unknown or under 3 doses
›Tetanus toxoid vaccine
›Dirty wound with unknown or under 3 doses
›Tetanus toxoid vaccine
›Tetanus immune globulin 250 units IM
›Irrigation and dressing principles
›Gross contamination removal at bedside if feasible
›High pressure irrigation deferred to OR debridement pathway when indicated
›Moist sterile dressing and splint
›Urgent operative timing principles
›Early debridement for gross contamination or vascular compromise
›Early fixation planning based on soft tissue status
DVT prophylaxis when relevant
›VTE prevention planning
›Risk factors
›Lower limb immobilization
›Planned operative fixation
›Prior VTE
›Active cancer
›Estrogen therapy
›Prolonged immobility
›Pharmacologic prophylaxis discussion
›Enoxaparin dosing per local protocol if admitted and no contraindications
›Hold if active bleeding or impending surgery per ortho plan
›Mechanical prophylaxis
›Intermittent pneumatic compression if admitted and pharmacologic held
›Documentation elements
›Indication and plan
›Contraindications if not used