Extremity Trauma: Fractures, Dislocations, Open Fractures and Amputations

Extremity trauma covers four limb-threatening injuries. Each one runs on its own clock: fracture, dislocation, compartment syndrome and traumatic amputation. An open fracture is one where a wound connects to the fracture. The Gustilo-Anderson grade (type I, II or III, with type III subdivided) tells you how big the wound is, how contaminated it is and how much soft tissue was hurt.

• Open fracture: the bone sees the outside world. Fracture-related infection (FRI) is the leading morbid complication, and it can lead to sepsis, nonunion and limb loss, per the 2024 OTA review.
• Knee dislocation: the tibiofemoral joint is completely displaced. A popliteal artery injury is the main threat to the limb. Ultra-low-velocity dislocations from low-energy falls, often in patients with obesity, are becoming more common, per the 2026 AAOS review.
• Hip dislocation: the femoral head is out of the acetabulum and needs prompt reduction under orthopedic protocol. Acute hip dislocation is classically reduced within 6 hours. The exact target depends on protocol.
• Compartment syndrome: pressure builds inside a closed fascial compartment and starves muscle and nerve of perfusion. Pain out of proportion to the injury comes first. The classic "5 P" findings (pulselessness, pallor, paresthesia, paralysis, poikilothermia) generally mean the diagnosis came late or was missed, per the 2026 JTACS review.
• Traumatic amputation: a body part is completely or partly separated. Replantation success depends on ischemic time, and on how the part is preserved in the first aid setting.

Limb bleeding has its own page: Hemorrhage Control. Shock from multiple injuries lives on Hemorrhagic Shock.

Fracture and Dislocation

• Deformity, shortening or abnormal position of the limb, point tenderness, crepitus and loss of function.
• Open fracture: any wound near the fracture counts, even a small puncture. Look for bone ends and contamination, and grade the wound on arrival.
• Knee dislocation: a displaced knee, or one that reduced on its own. Treat it as a suspected knee dislocation. Run serial vascular examinations until the limb is cleared, as the 2026 AAOS review advises.
• Hip injury in an older adult: groin or hip pain after a fall, and the patient can't bear weight. A hip fracture and a hip dislocation can coexist with other injuries.

Neurovascular Injury and Compartment Syndrome

• Pulse, color, temperature, capillary refill, sensation and motor function distal to the injury, compared with the other limb.
• Pain out of proportion to the injury, or pain that keeps rising or does not respond to analgesics, per the 2026 JTACS review.

Red Flags

• Absent or weak distal pulse, pallor, cold limb, or new numbness or weakness
• Pain out of proportion, or pain not relieved by analgesics
• Bleeding that continues under direct pressure, or a limb attached only by soft tissue
• Knee dislocation with any change in vascular status

The ankle-brachial index and imaging thresholds change from one institution to the next. Follow the local pathway.

• Nerve injury versus arterial injury: both cause numbness and weakness after a dislocation. The pulse alone won't sort them out. Document both and reassess serially.
• Fracture pain versus compartment syndrome: pain that persists or climbs despite analgesia and immobilization points to compartment syndrome until proven otherwise, per the 2026 JTACS review.
• Hip fracture versus hip dislocation: both cause severe pain and an inability to move the leg. A dislocation is a reduction emergency. Image the hip and tell orthopedics early.
• Spontaneously reduced knee versus intact ligaments: a knee that reduced on its own still needs serial vascular examinations, per the 2026 AAOS review.

1. Scene safety and mechanism: note the energy of the injury (fall height, crash, crush), how long the limb was trapped, and the time of injury.
2. Control bleeding: direct pressure, hemostatic packing for deep wounds, and a pressure dressing. Use a tourniquet first for massive or pulsatile limb bleeding that pressure cannot stop, and note the time applied (see Hemorrhage Control). Femur and pelvic fractures can bleed heavily; for suspected pelvic fracture, apply a pelvic binder per protocol (see Abdominal and Pelvic Trauma).
3. Open fracture: cover the wound with a sterile dressing. Do not probe the wound or push protruding bone back in.
4. Neurovascular check before and after splinting: record pulse, color, temperature, sensation and movement distal to the injury, and repeat after every move.
5. Splint: immobilize the joints above and below the injury. Do not force a deformity straight. Exception: if the distal pulse is absent or the limb is cyanotic, gently realign once with traction, per protocol, then splint and recheck the pulse. Reduction of a dislocation is an ALS decision per protocol. A traction splint is for an isolated mid-shaft femur fracture only; do not use one with pelvic, hip, knee or ankle injury, or with open or exposed bone at the traction site.
6. Suspected compartment syndrome: pain out of proportion, a tight or tense compartment, or numbness. Loosen or remove circumferential dressings, splints and casts; do not apply a constricting splint or wrap to a tense limb. Keep the limb at heart level and do not elevate it; do not apply ice. Avoid hypotension, treat pain, and transport as a priority.
7. Amputated part: wrap the part in saline-moistened gauze, seal it in a plastic bag, and cool it without freezing, per protocol. Record the time of amputation and send the part with the patient, per protocol.
8. Transport priority: open fracture with uncontrolled bleeding, pulseless or cold limb, suspected knee dislocation, amputation, or suspected compartment syndrome go as priority transports.

Doses vary by protocol; follow local protocols and medical direction.

• IV or IO access (Paramedic/RN/CCT): for analgesia, sedation, antibiotics or hemorrhage. See IV Insertion and IO Access.
• Open-fracture antibiotic (Paramedic/RN/CCT): give a first-generation cephalosporin as soon as possible for a suspected open fracture, after life threats are managed. Do not delay transport. Per the 2024 joint position statement: responsive with no penicillin or cephalosporin allergy, give it; obtunded, give it after life threats, also without delaying transport; responsive with a documented penicillin allergy, give it with close monitoring. The statement does not address a history of cephalosporin allergy or anaphylaxis: do not give cefazolin without medical direction, and follow protocol. The statement names cefazolin without a dose. The usual adult dose is 2 g IV, or 3 g for 120 kg or more, per the 2013 ASHP/IDSA/SIS/SHEA surgical prophylaxis guideline (Table 1); the dose is set by local protocol and medical direction. Timing: give as soon as possible; many protocols use 60 minutes from injury (see Clinical Pearls for the evidence on timing).
• Analgesia (Paramedic/RN/CCT): fentanyl 1 mcg/kg IV/IO slowly (max initial 100 mcg), repeated after at least 5 min per protocol. See Fentanyl. Morphine 0.1 mg/kg IV/IO slowly (max 10 mg initial dose) is an alternative. See Morphine. Reassess respiratory rate, SpO₂, blood pressure and level of consciousness after each dose, and have naloxone ready. Opioids and ketamine can both lower blood pressure and depress breathing in a bleeding patient; in suspected hemorrhagic shock or hypotension, reduce the dose or choose the agent per protocol. A long-bone fracture or amputation can hide occult shock. Reduce doses in older or frail patients. A fascia iliaca or femoral nerve block is an opioid-sparing option where protocol and training allow.
• Ketamine for pain (Paramedic/RN/CCT): 0.1–0.3 mg/kg IV over 10–15 min (max 0.35 mg/kg), per protocol. See Ketamine.
• Sedation for reduction (Paramedic/RN/CCT): per the local procedural sedation protocol, with monitoring of ventilation and oxygenation throughout.
• Reduction of a dislocation (Paramedic/RN/CCT, per protocol): reduce only as protocol and medical direction allow. Recheck neurovascular status immediately after reduction and after each move.
• Hemorrhage (Paramedic/RN/CCT): for significant hemorrhage or hemorrhagic shock, per protocol: tranexamic acid 1 g IV/IO over 10 min, then 1 g over 8 hr, given within 3 hours of injury. Not for an isolated fracture without significant bleeding. See Tranexamic Acid for contraindications and cautions. Blood products per the trauma protocol.

• Imaging and vascular work-up: image the injured limb and the joints above and below. For suspected vascular injury, use ABI and CT angiography, per the pathway above. Consult vascular surgery emergently for a limb with vascular compromise, per the 2026 AAOS review.
• Knee dislocation: keep doing serial vascular examinations. A knee that won't reduce by closed means goes emergently to the operating room for open reduction. Temporary external fixation is the exception. It is reserved for a knee that stays subluxated or unstable after reduction or bracing, severe open wounds, associated fractures that need stabilization, or a vascular procedure. When to operate on the ligaments is still debated, per the 2026 AAOS review.
• Open fracture: keep antibiotics going per protocol. Give prophylaxis within 60 minutes before surgery, and continue it up to 24 hours after surgery, per the 2024 OTA review. Sort by Gustilo-Anderson type. For type I and II, a first-generation cephalosporin alone is the standard. For type III, gram-negative coverage depends on protocol. The OTA review says it may help for a short time. A 2023 retrospective national cohort of 1,041 type III fractures found no significant difference in deep infection between narrow- and broad-spectrum antibiotics. That is limited evidence, and it does not settle practice. For gross fecal or soil contamination, add anaerobic coverage per protocol. For a penicillin allergy, use a non-beta-lactam alternative per protocol, such as clindamycin or vancomycin. Soft-tissue coverage in severe injuries should happen close to fixation, ideally within 48 hours, per the 2024 OTA review.
• Tetanus (2018 ACIP): a contaminated wound, open fractures included, gets a tetanus-containing vaccine if the last dose was more than 5 years ago, or if the history is unknown or fewer than 3 doses. Add tetanus immune globulin only if the history is unknown or fewer than 3 doses. A clean minor wound gets a vaccine if the history is unknown or fewer than 3 doses, or if the last dose was more than 10 years ago. Tdap is preferred for persons aged 11 years or older who have not had Tdap.
• Compartment syndrome: urgent fasciotomy. Early fasciotomy is the only effective treatment, per the 2026 JTACS review. A measured compartment pressure supports the clinical exam. It does not replace it. A delta pressure (diastolic blood pressure minus compartment pressure) of 30 mmHg or less is commonly used as the threshold for fasciotomy. Pressure matters most in obtunded or sedated patients, because they cannot report pain. An open fracture does not rule out compartment syndrome. Document serial exams.
• Amputation: transfer to a center that can replant, per the regional system. The surgical team makes the replantation call.
• Hip fracture in older adults: surgical fixation or arthroplasty is the usual treatment. It happens promptly once the patient is medically optimized, per the orthopedic pathway. The 2021 AAOS guideline (summary published 2022) covers surgical care for adults 55 and older. Optimization and timing both follow the orthopedic pathway.
• Hip dislocation: reduce promptly under orthopedic protocol. The classic teaching target is within 6 hours, but the exact target depends on protocol. Delay raises the risk of avascular necrosis of the femoral head and, with posterior dislocation, sciatic nerve injury.
• Fat embolism: after a long-bone or pelvic fracture, watch for new hypoxia, confusion or petechiae. Treat per the ICU respiratory protocol.

• Destination: send open fractures, amputations and vascular compromise to a trauma center. A knee dislocation with vascular compromise needs vascular surgery on arrival, per the regional system.
• Continue in transit: neurovascular checks at every reassessment, splint and dressing checks, and bleeding control. Keep the amputated part cooled, bagged and labeled, per protocol.
• Medications in transit: redose analgesia by protocol and reassess breathing after each dose. Note the time the cephalosporin was given.
• Air transport: recheck splints and dressings after any change in altitude, per flight protocol.
• Handoff: mechanism and time of injury, neurovascular status at each check, antibiotic drug and time, tranexamic acid time and dose, analgesic doses and times, tetanus status, and the time the amputated part was wrapped and cooled.

• Pediatrics: dose by weight, and read vital signs against age-specific thresholds (see Weight-Based Dosing and Vital Signs). The same neurovascular checks apply. Fentanyl: IV/IO 1 mcg/kg slowly (max initial 100 mcg), or intranasal 1.5 mcg/kg split between nares (max 75 mcg; from 12 months of age); see Fentanyl. Ketamine for pain: 0.1–0.3 mg/kg IV or 1–1.5 mg/kg IN; see Ketamine. Cefazolin IV is 30 mg/kg per the 2013 ASHP/IDSA/SIS/SHEA guideline (Table 1), capped at the adult dose. Pediatric protocol sets it. Growth-plate (physeal) injury can be subtle on radiographs. Treat growth-plate tenderness as a possible fracture. A young child with an unexplained fracture, or a history that does not fit the injury, gets screened for non-accidental trauma per protocol. Pediatric compartment syndrome often shows up as the 3 A's (anxiety, agitation and an increasing need for analgesia). Young children may not be able to describe the pain. Morphine is off-label in children. The dose is 0.05 to 0.1 mg/kg IV/IO slowly and per-dose caps set by local pediatric protocol (see Morphine). This page does not set pediatric fracture management. Follow pediatric trauma and orthopedic protocols.
• Pregnancy: fracture care does not change. Imaging and drug choices do. Make those choices with obstetric input and the medication pages. Use shielded imaging when it is needed, and monitor fetal status per the local protocol. After about 20 weeks of gestation, tilt the patient left (left uterine displacement, left lateral tilt) to relieve aortocaval compression during care and transport.
• Older Adults: surgery follows the AAOS guideline (see ED & ICU Management). Titrate analgesia to effect. Watch respiratory rate and level of consciousness after every dose.
• Patients on Anticoagulants: bleeding risk runs higher, and hematomas can grow. Reverse anticoagulation per the local protocol. For warfarin, see Prothrombin Complex Concentrate.
• Obesity: ultra-low-velocity knee dislocations from low-energy falls are more common in these patients, per the 2026 AAOS review. Don't assume a low-energy mechanism means a minor injury.
• Renal Impairment: a limb under prolonged compression raises concern for crush injury and rhabdomyolysis. Follow the local rhabdomyolysis protocol before fluid and drug decisions in patients with kidney impairment.
• Crush Injury: prolonged entrapment (more than 1 hour) calls for early IV fluid per protocol, ECG monitoring for hyperkalemia, and protocol-directed treatment of hyperkalemia.

• Error: splinting or reducing a limb and not rechecking the pulse, color and sensation. Recheck after every move and write down the time.
• Error: trusting a normal pulse to rule out compartment syndrome or arterial injury. Losing the pulse is a late finding, per the 2026 JTACS review.
• Error: holding the open-fracture antibiotic for imaging or a long scene time. Give it as soon as possible. It should not hold up transport, per the 2024 joint position statement.
• Error: treating the pain and never looking at the compartment. Analgesia can mask a compartment syndrome that is evolving. Reassess when the pain rises or stops responding.
• Error: freezing the amputated part, or leaving it unwrapped and dry. Wrap it in saline-moistened gauze, bag it and cool it without freezing, per protocol.
• Error: putting a tourniquet over a joint, or too far from the bleeding. Place it 2 to 3 inches (5 to 7 cm) above the wound, not over a joint. Can't find the wound? Place it high and tight. Tighten until the bleeding stops and the distal pulse is gone. Add a second if needed, and record the time. Don't loosen it in the field unless protocol directs.
• Error: calling a knee dislocation safe because the pulse came back after reduction. Keep up serial vascular exams and an ABI when available, per the 2026 AAOS review and the 2025 JBJS cohort.