Closed Reduction/Splinting/Casting Procedure Note

Procedure: [Procedure name and description of closed reduction with splinting or casting]

Side/Site: [Laterality and specific anatomic location]

Date/Time: [Procedure start time – end time]

Location: [ED / clinic / procedure room / bedside]

Operator(s): [Performing clinician and assistants]

Pre-procedure Diagnosis: [Injury type and pattern if known]

Post-procedure Diagnosis: [Updated diagnosis if changed, or same as pre-procedure]

Indication

[Reason for reduction and/or immobilization; mechanism and timing] (One to two sentences. If pre-reduction imaging deferred, state rationale.)

Consent

[Consent type: verbal / written] obtained from [patient / parent / guardian / healthcare proxy]. Patient had capacity to consent. Risks, benefits, and alternatives were discussed, including failed or incomplete reduction, need for operative management, neurovascular injury, compartment syndrome, and recurrent instability. [Additional sedation risks discussed if applicable]

(If emergent necessity precluded consent, explicitly document reason rather than omitting this section.)

Time-Out

Time-out performed confirming patient identity, procedure, site/laterality, imaging availability, and allergies. (If not performed due to immediate limb threat, document reason.)

Pre-Procedure Neurovascular Exam

• Perfusion: [Named distal pulses; capillary refill; skin temperature and color]
• Sensation: [Nerve distributions assessed and findings]
• Motor: [Specific muscle actions tested and findings]
• Skin: [Integrity; tenting or blanching; swelling severity; open wound if present]

(Document baseline prior to any manipulation. If any component cannot be assessed, state "unable to assess" with reason; do not document intact for elements not examined.)

Anesthesia/Sedation

(Include only the applicable pathway below; omit non-applicable options.)

• No sedation: [Analgesics administered or reference to MAR]
• Local/Regional anesthesia: [Agent; concentration; volume; route/site; technique: landmark / ultrasound-guided; adequacy of anesthesia]
• Procedural sedation:
  • [Intended sedation level: minimal / moderate / deep]
  • [Sedation clinician and monitoring roles]
  • [Pre-sedation evaluation; airway assessment; fasting status if known]
  • [Monitoring: pulse oximetry; capnography; BP frequency; cardiac monitor if used]
  • Medications: [Drug, dose, route, time for each administration]
  • [Sedation start time; end time; total face-to-face minutes]
  • [Adverse events and interventions, or none]
  • [Return to baseline mental status confirmed; responsible adult present]

(If sedation documented in separate nursing record, reference that record but still include medications, complications, and time accounting here.)

Reduction

• Technique: [Patient positioning and named maneuvers used]
• Attempts: [Number of attempts] (If multiple, note neurovascular reassessment between attempts.)
• Outcome: [Successful / partially successful / unsuccessful] (If unsuccessful, document escalation plan.)

(If reduction was emergent due to neurovascular compromise or threatened skin, state urgency rationale.)

Immobilization

• Type: [Splint / cast; prefabricated / custom]
• Configuration: [Specific name: sugar-tong / posterior long arm / ulnar gutter / thumb spica / short leg posterior with stirrup / other]
• Materials: [Fiberglass / plaster; padding type]
• Position: [Relevant joint angles]
• Modifications: [Bivalved / univalved / windowed / additional padding] (Include only if applicable.)
• Tolerance: [Pressure points addressed; patient comfort]

Post-Procedure Neurovascular Exam

• Perfusion: [Named distal pulses; capillary refill; skin temperature and color]
• Sensation: [Nerve distributions assessed and findings]
• Motor: [Specific muscle actions tested and findings]
• Comparison to baseline: [Improved / unchanged / worsened]

(Document after immobilization is secured. If any new deficit identified, document immediate actions taken.)

Imaging

• Pre-reduction: [Views obtained and key findings] (If deferred, state reason.)
• Post-reduction: [Views obtained; interpretation source: clinician preliminary / radiology read; result: reduction confirmed / alignment improved / residual displacement / associated fracture identified] (If pending, state "results pending—will addend." If deferred, document reason and clinical confirmation method.)

Complications

[Complications during procedure with management actions / None]

Disposition and Follow-Up

• Disposition: [Discharge / admit / transfer] (If transferred, include consultant acceptance.)
• Follow-up: [Specialty; timeframe; scheduled / advised]
• Weight-bearing: [NWB / PWB / WBAT / not applicable]
• Activity restrictions: [Sling use; elevation; digit ROM exercises as applicable]
• Medications: [New prescriptions for pain control]
• Return precautions: Instructed to return for increasing pain or tightness, numbness or tingling, weakness, color change or coolness of digits, inability to move fingers/toes, increasing swelling, or wet/damaged splint/cast.

(If sedation performed, document return to baseline, responsible adult present, and driving/machinery restrictions.)