OAK: Fracture Reduction and Fluoroscopy Protocol for APPs

APP Fracture Reduction Workflow

Emergency Department — Advanced Practice Provider Protocol

Background

APPs (Physician Assistants and Nurse Practitioners) are not licensed to independently operate fluoroscopy equipment (C-arm). Therefore, APPs may perform fracture reductions but may not operate the C-arm for live fluoroscopic imaging.

Workflow

1.  Fracture Reduction Requiring Post-Reduction Imaging Only

  • The APP may perform the fracture reduction.

  • A portable X-ray will be obtained after the reduction is completed to assess alignment and reduction success.

 

2.  Fracture Reduction Requiring Live Fluoroscopy

  • The APP must notify the Emergency Department team in advance that live fluoroscopy will be required.

  • If a licensed orthopaedic resident or attending is not available, a licensed radiology technologist must be called to the Emergency Department to operate the C-arm.

 

Communication Responsibilities

Prior to the procedure, the APP is responsible for communicating to the ED whether:

  • Post-reduction portable X-rays only will be needed, or

  • Live fluoroscopy will be required during the reduction. If a licensed ortho resident/attending is not available to assist, the APP will notify the ED team that a tech will be required to operate the mini C-arm. The APP will contact the radiology tech with the anticipated start time for reduction after discussing with the ED team.

This communication should occur early enough to allow appropriate imaging resources to be coordinated.

Daytime Coverage

  • During weekday daytime hours (Monday–Thursday, 7:00 AM–3 PM and Friday 7am – 11am), this workflow will be utilized.

  • The APP is responsible for contacting the radiology tech and notifying of when the anticipated reduction start time will be. 

Existing Process

This workflow mirrors the existing process currently used for Emergency Medicine residents who do not hold fluoroscopy licenses and extends the same process to APPs.

 

Version: 1.0

Creation: 6/2026

Approved by: Swarup, Pandya (Orthopedics); Daftary, Mansour (PEM)

Disclaimer: This workflow serves as a guideline only and should not replace clinical judgment.