Free Closed Fracture Reduction Consent Form Template

Informed Consent for Closed Fracture Reduction and Immobilization

Patient Informed Consent Documentation

Patient and Provider Information

What This Procedure Involves

A closed fracture reduction is a procedure that moves a broken bone back into its correct position without making a surgical incision. It is called 'closed' because the skin is not opened. The procedure is most commonly performed on fractures of the wrist, ankle, forearm, and fingers, where bones have shifted out of alignment. The steps are: (1) The affected limb is assessed with X-ray imaging to confirm the fracture pattern and degree of displacement. (2) Pain relief is given. This may be oral medication, IV analgesia, a local nerve block, or procedural sedation depending on the fracture, patient age, and level of pain. (3) The provider applies traction and manipulation to move the bone fragments back into the correct position. This is done by feel and checked with repeat imaging. (4) Once the bone is in an acceptable position, the limb is placed in a splint, backslab, or cast to hold it in place while healing occurs. A repeat X-ray confirms the position after immobilization. Most fractures take 4 to 8 weeks to heal and require orthopedic follow-up within 5 to 7 days.

Pain Relief and Sedation Options

The provider has recommended the following approach to pain management for this reduction: [Provider to select and specify]. Options include: (1) Oral or IV analgesics: pain medications given to reduce discomfort but without causing unconsciousness. The patient remains fully awake. (2) Local or regional nerve block: a local anesthetic is injected near the nerve that supplies feeling to the fracture area. The arm, hand, or foot becomes numb for the duration of the procedure. (3) Procedural (conscious) sedation: IV medication is given to cause deep relaxation and reduce memory of the procedure. The patient remains breathing on their own but is not fully awake. Procedural sedation requires fasting (nothing by mouth for 2 to 6 hours) and requires additional monitoring and a longer stay in the department. A separate sedation consent form is required.

Risks and Possible Complications

Alternatives to Closed Reduction

Neurovascular Check Acknowledgment

I understand that a neurovascular check (assessment of circulation, sensation, and movement in the limb below the fracture site) will be performed before and after the reduction procedure. I agree to immediately report any numbness, tingling, skin color changes, or inability to move fingers or toes after discharge. I understand that increasing pain not controlled by prescribed pain medication after the procedure is also a sign that requires urgent evaluation.

Cast and Splint Care Instructions

The patient agrees to: (1) Keep the cast or splint dry unless given a specific waterproof cast. Cover it with a plastic bag during bathing. (2) Elevate the injured limb above heart level for the first 48 hours to reduce swelling. (3) Do NOT insert any objects inside the cast to scratch the skin. This can cause skin breakdown and infection. (4) Return to the emergency department immediately if the cast feels too tight, causes uncontrolled pain, or if fingers or toes become numb, pale, cold, or unable to move. (5) Attend the orthopedic follow-up appointment within 5 to 7 days as arranged.

Right to Refuse Treatment

The patient has the right to refuse closed reduction. The provider will explain the risks of leaving a displaced fracture untreated, which may include permanent deformity, chronic pain, loss of function, and the need for more complex surgery later. Refusing this procedure does not affect the patient's right to seek further care.

Patient Understanding

I confirm that I have read this consent form or had it explained to me. I have asked questions about the procedure, the analgesia plan, the casting process, and the follow-up requirements. All my questions have been answered. I understand the importance of attending the orthopedic follow-up appointment and monitoring my limb for signs of complications.

Language Access

If English is not your main language, a qualified interpreter is available at no cost. Please notify staff before any treatment begins.

Copy of Consent

I acknowledge that I have been offered a copy of this signed consent form for my records.

Patient Authorization

I voluntarily agree to closed fracture reduction and immobilization as described in this form. I agree to follow the cast care instructions, to monitor for warning signs of complications, and to attend my orthopedic follow-up appointment. I understand and accept the risks, including the possibility that surgery may be needed if the reduction is unsuccessful or if the bone shifts after the procedure.

Signatures and Verification