Module 13 · Musculoskeletal | NUR198 Final Exam Study Guide

🎯 Read this even if you read nothing else high yield

Ten rules. If you only have five minutes before the exam, these are the five minutes.

⭐ The ten that show up

Paresthesia (numbness/tingling) is the FIRST sign of compartment syndrome — not pain, not pulselessness. Pulselessness is late. If you wait for it, the limb is already in trouble.
Compartment syndrome = emergency. Loosen the dressing, do not elevate above heart level, notify the provider, prepare for fasciotomy.
Fat embolism: 12–48 hr after a long-bone or hip fracture. The finding that separates it from a PE is petechiae on the neck, chest, upper arms and abdomen.
Neurovascular checks: every hour for the first 24 hr, then every 1–4 hr.
Traction weights hang free. Never lift, remove or rest them on the floor unless the prescription says traction may be removed.
One swab per pin. That single sentence answers most pin-care questions.
Total hip: no flexion past 90°, no crossing legs, no internal rotation, no low chairs, no lying on the operative side.
Hip dislocation sounds like a “pop” and looks like a shortened, rotated leg with sudden pain.
Oral bisphosphonate: early morning, empty stomach, 8 oz water, stay upright 30 min.
Phantom limb pain is real pain and it is treated differently — antidepressants and anticonvulsants, not just opioids.

🚨 Ruby = act now

Compartment syndrome, fat embolism, hip dislocation, pin-site infection with spreading redness. These are the “notify the provider” answers.

⭐ Topaz = high yield

The 6 P’s, traction weight rules, hip precautions, bisphosphonate teaching. Expect at least one question on each.

🧠 Teal = definitions

Malunion vs nonunion, skin vs skeletal traction, OA vs RA. Exams love a pair you can mix up.

🧡 Neurovascular assessment do this first

Every immobilized limb, every shift, and every time she says something changed.

⏰ How often

first 24 hrEvery hour

Swelling peaks here, and so does the risk.

after 24 hrEvery 1–4 hr

Per the order and how the limb looks.

any changeReassess now

New numbness or pain out of proportion → full check.

Always compare with the unaffected limb. That comparison is what makes a finding meaningful.

✍️ What you check — and what abnormal means

Check	Normal	Abnormal means
Pain	Relieved by immobilization, ice, elevation and ordered analgesics	Pain out of proportion, or pain on passive movement → think compartment syndrome
Paresthesia (sensation)	No numbness or tingling	Numbness or tingling = nerve compromise. Earliest sign of compartment syndrome.
Pallor (color & temperature)	Warm, normal color	Cool and pale = decreased arterial perfusion. Cyanotic nail beds = venous congestion.
Capillary refill	Blood returns in < 3 seconds	Prolonged refill = decreased arterial flow
Pulses	Palpable, strong, equal to the other side	Weak or unequal = perfusion problem. Edema can hide a pulse — use Doppler before you call it absent.
Paralysis / movement	Active movement of the limb	Cannot move fingers or toes = late, serious. Do not wait on it.
Pressure	Compartment soft to palpate	Hard, tight, swollen muscle = rising compartment pressure

⭐ Memory hook6 P’s — Pain, Pressure, Paralysis, Paresthesia, Pallor, Pulselessness. They are listed in a tidy order but they do not happen in that order: paresthesia comes first, pulselessness comes last.

🦴 Fractures core content

Type, then risk, then what you do in the first hour.

🧿 Fracture types

🖼️ Fracture typesTap to open it full size

Type	What it is
Complete	Bone is broken all the way through, into two or more pieces
Incomplete	The break goes only partway across the bone
Closed / simple	Skin is intact over the break
Open / compound	Skin is broken — infection risk, graded by how much soft tissue is damaged
Comminuted	Bone is fragmented into several pieces
Oblique	Break runs at an angle across the bone
Spiral	Break winds around the bone — from a twisting force
Transverse	Straight across the bone
Greenstick	One side bends, the other side breaks — children
Impacted	One bone end is driven into the other
Compression	Bone collapses on itself — classic in the vertebrae with osteoporosis
Pathologic	Break through bone already weakened by disease (tumor, osteoporosis)
Stress / fatigue	Repetitive load, no single injury
Displaced	The bone ends are out of alignment

⚠️ Who breaks bones

Osteoporosis — the biggest one, and it makes an ordinary fall a fracture
Falls — and older adults fall more, and heal slower
Motor vehicle crashes
Substance use disorder
Low vitamin D — no vitamin D, no calcium absorption, weaker bone
Physical abuse — injuries that do not match the story
Advancing age — bone becomes less dense

Prevention teaching

Calcium and vitamin D, weight-bearing exercise
Home fall-proofing: lighting, cords, rugs, grab bars, non-skid shoes
Review medications that cause orthostatic hypotension, urinary frequency or confusion — those raise fall risk
Helmets and seat belts — boring and still tested

🔍 What you find

Subjective

Pain, often immediate and severe
Numbness or tingling distal to the injury
Report of hearing or feeling a snap
Loss of function

Objective

Deformity, shortening, obvious malalignment
Swelling and ecchymosis
Crepitus (grating with movement — do not go looking for it, you can worsen the injury)
Muscle spasm, guarding
Open wound with bone visible in a compound fracture

Labs and diagnostics

Test	Why it matters
Hgb & Hct	Drop with blood loss — a femur or pelvic fracture can bleed a lot
WBC	Rises with infection, and after trauma
ESR	Rises with inflammation — used with suspected osteomyelitis
Calcium, phosphorus, alkaline phosphatase	Bone metabolism and healing
Creatinine	Baseline before contrast studies and NSAIDs
X-ray	First-line; confirms the fracture and the alignment
CT / MRI	Soft tissue, ligaments, occult and complex fractures
Bone scan	Occult fractures, infection, tumor

🚑 First hour — the order matters

1ABCs first

Airway, breathing, circulation, and control bleeding. A fracture never outranks an airway.

2Immobilize

Splint above and below the site, in the position found. Do not try to realign it.

3Neurovascular check

Before and after every splint, cast or move. Document both.

4Ice, elevate, analgesia

Cold and elevation for the first 24–48 hr. Cover an open fracture with a sterile dressing.

🚨 Do notDo not move the limb to "see if it works." Do not push protruding bone back in. Do not massage the extremity — you can dislodge a clot or fat globules.

🧾 When healing goes wrong

Term	What happened
Malunion	The fracture healed, but incorrectly — angled or rotated
Nonunion	The fracture never healed
Delayed union	Healing is slower than expected for that bone
Avascular necrosis	Blood supply was disrupted → bone tissue died. Common in hip fractures and displaced fractures

Risk factors for avascular necrosis: long-term corticosteroid use, radiation therapy, rheumatoid arthritis, sickle cell disease. Treatment can mean a bone graft or a prosthetic replacement.

🪛 Immobilization & casts core content

Six ways to hold a bone still, then everything about casts.

🧰 The six devices — know which is which

Device	What it does / when
Brace	Supports and holds alignment; can usually be removed
Cast	Rigid, circumferential; secures the limb after reduction
Splint / immobilizer	Non-circumferential, removable; often used before the swelling settles
Traction	A pulling force to align and hold; weights and ropes
External fixation	Percutaneous pins and wires attached to a rigid external frame
Internal fixation	Surgical — plates, screws, rods, pins inside the body (ORIF)

🧠 Closed reductionRealigning the bone without surgery — manual traction under sedation or anesthesia, then immobilized. Open reduction means the surgeon opens the site, usually with internal fixation (ORIF).

🚨 External fixation used forComminuted or nonunion fractures with extensive soft tissue damage · leg length discrepancies from congenital defects · bone loss from tumors or osteomyelitis. Pins go through the skin, so pin care and infection watch are the nursing job.

🪛 Plaster vs. fiberglass

🖼️ Cast careTap to open it full size

	Plaster of Paris	Synthetic fiberglass
Weight	Heavy	Light
Water	Not water-resistant	Water-resistant
Drying time	24–72 hr	about 30 min
Strength	Adequate; molds well	Stronger
Used	Less often now	Most common

⭐ The plaster questionWhile a plaster cast is wet: handle it with the palms, never the fingertips — fingertips leave dents, and a dent becomes a pressure point on skin you cannot see. Let warm dry air circulate, use a cloth-covered pillow, not plastic, and keep it off hard surfaces and sharp edges.

✅ Nursing actions

Neurovascular check every hour for the first 24 hr; assess pain each time
Ice for 24–48 hr
Elevate for the first 24–48 hr to prevent edema — arm cast above heart level, leg cast on several pillows at rest
Check fit: one finger should fit between the skin and the cast
Inspect the cast every 8–12 hr; document and report a sudden increase in drainage
Provide the assistive device — sling for an arm cast, cast shoe or boot for walking
Older adults: higher skin-breakdown risk from thinner skin and reduced sensation

Circling drainage on the cast is not a reliable measure of how much there is — and it tends to frighten the client. Describe and report it instead.

👤 What she teaches the client

Never put anything inside the cast — no coat hangers, no pencils, no knitting needles
Itching: blow cool air from a hair dryer into the cast
Cover with plastic for showers, and before toileting if soiling is a risk
Report a “hot spot,” new pain, increased drainage, warmth or odor — that is infection
Report shortness of breath, new numbness, skin breakdown, constipation
Expect the cast to loosen once the swelling goes down — it may need replacing

🚨 Teach her to call immediately forNumbness or tingling · pain that keeps getting worse despite medication · fingers or toes that turn cold, pale or blue · inability to move fingers or toes. Those are compartment syndrome words.

⚖️ Traction & pin care high yield

Traction is a pulling force. Almost every test question is about the weights or the pins.

🎯 What traction is for

🖼️ Buck’s traction & post-op careTap to open it full size

Prevent soft tissue injury
Realign bone fragments
Decrease muscle spasms and pain
Correct or prevent further deformity

📋 The prescription must sayThe type of traction · the amount of weight · and whether traction may be removed for nursing care. If it does not say removable, it is not.

⚖️ Skin vs. skeletal — the comparison they test

	SKIN traction	SKELETAL traction
How it attaches	To the skin — tape, straps, boots or cuffs	Screws or pins into the bone
Weight	Light: 5–10 lb	Heavier: 15–30 lb
Main purpose	Decrease muscle spasm and immobilize the limb, often before surgery	Realign the bone, over a longer period
Examples	Buck’s — preoperative hip fracture in adults Bryant’s — congenital hip dislocation in children	Balanced suspension · halo traction
Infection risk	Skin breakdown under the straps	Pin-site infection — pin care every shift

🧠 Straight vs. balanced suspensionStraight (running) traction pulls in one straight line and uses the client’s own body as counter traction — so if she moves, the traction changes. Balanced suspension uses slings or splints to hold the limb off the bed, so the client can move without changing the traction.

✅ Traction nursing actions

Neurovascular check every hour for 24 hr, then every 4 hr
Keep body alignment; realign if she looks uncomfortable or reports pain
Do not lift or remove the weights
Weights hang freely — never resting on the floor or the bed frame
If a weight gets knocked off, put it back; if that does not fix the problem, notify the provider
Check ropes and pulleys every 8–12 hr for knots, fraying, looseness and bad positioning
Notify the provider for severe spasm pain not relieved by medication or repositioning
Heat or massage as prescribed for muscle spasm; therapeutic touch and relaxation help
Monitor and document skin integrity routinely

🚨 Halo tractionMove the client as a unit. Never pull, push or lift by the rods — it loosens the pins and it hurts. Keep a wrench taped to the vest for emergency removal, and never turn the client using the frame.

🧿 Pin site care

⭐ The one-line answerOne cotton swab per pin. A swab that touches two pins carries organisms from one to the other.

How often

Usually once a shift, 1–2 times a day, or per facility protocol
Increase the frequency if drainage increases or infection is suspected

What you look for

Drainage — color, amount, odor
Redness around the site
Loosening of the pins
Tenting — skin rising up along the pin

What you use

Chlorhexidine is common, but the protocol is set by the provider and the facility
Do not tighten a loose pin yourself — report it
Crusting: follow the facility protocol; do not pick crusts off on your own initiative

🚨 Complications emergency content

This is where the priority questions live. Learn the first sign and the time window for each.

🚨 Compartment syndrome — medical emergency

What it is: pressure builds inside a closed muscle compartment, blood flow is restricted, and the resulting ischemia causes irreversible tissue damage. The fascia will not stretch, so the pressure has nowhere to go.

firstParesthesia

Numbness and tingling. This is the earliest sign.

thenPain

Worsening, out of proportion, and worse on passive movement.

thenPressure & pallor

Hard swollen muscle; the distal area turns pale and cool.

lastPulselessness & paralysis

Cannot move the hand or foot. Late — do not wait for this.

⚡ What you do, in order1. Recognize it and notify the provider immediately. 2. Loosen the dressing or bivalve the cast per order. 3. Keep the limb at heart level — do not elevate above the heart, which drops arterial flow further, and do not apply ice, which constricts. 4. Prepare to assist with a fasciotomy — a surgical opening into the tissue to relieve pressure and save the limb.

⭐ Exam tell“Pain rated 10/10 when the foot is passively moved” and “hard, swollen muscle” are compartment syndrome. A capillary refill of 2 seconds and 2+ pulses are normal — they do not rule it out, because perfusion changes come late.

🦠 Fat embolism syndrome

🖼️ Fat embolism & osteomyelitisTap to open it full size

What it is: fat globules from bone marrow enter the bloodstream, lodge in small vessels including the lungs, and cause acute respiratory insufficiency and impaired organ perfusion.

When

12–48 hr after the injury — after long bone fractures or total joint arthroplasty. Most common after fracture of the hip, pelvis or long bones.

Early findings

Dyspnea, respiratory distress
Increased heart rate and respiratory rate
Hypoxemia, falling oxygen saturation
Confusion from low arterial oxygen
Hypotension
Chest pain

⭐ The discriminatorCutaneous petechiae — pinpoint subdermal hemorrhages on the neck, chest, upper arms and abdomen. It is a late finding, and it is what tells fat embolism apart from a pulmonary embolism.

💉 TreatmentOxygen for respiratory compromise · corticosteroids for cerebral edema · vasopressors and fluid replacement for shock · pain and anti-anxiety medication as needed.

Prevention: immobilize the fracture early, handle the limb gently, and do not massage the extremity.

🦠 Venous thromboembolism (VTE)

Why it happens here: venous stasis from immobility, endothelial injury from the trauma or surgery, and hypercoagulability. All three of Virchow’s triad at once.

DVT findings

Calf or thigh swelling, redness, warmth, pain
Often unilateral

PE findings

Sudden dyspnea, chest pain
Tachycardia, tachypnea, anxiety, falling SaO₂

✅ PreventionEarly ambulation · ankle pumps and leg exercises · sequential compression devices · prophylactic anticoagulation · adequate hydration. Never massage a suspected DVT.

🦠 Osteomyelitis

What it is: infection of the bone, beginning as inflammation inside the bone after organisms get in — usually after trauma (open fracture) or surgical repair.

Findings

Bone pain that is constant, pulsating, localized, and worse with movement
Erythema and edema at the site
Fever — but older adults may not run a temperature
Leukocytosis, possibly elevated ESR
Many of these findings disappear if it becomes chronic — which is why it gets missed.

Diagnosis & treatment

Bone scan or MRI; cultures for aerobic and anaerobic organisms; blood cultures if septicemia develops
At least 4–6 weeks of IV and oral antibiotics
Surgical debridement; bone graft if a lot of bone must come out
Antibiotic beads in bone cement can be implanted into the wound
Unsuccessful treatment can end in amputation

✅ NursingGive antibiotics on schedule to keep a constant blood level · analgesics as needed · neurovascular checks after debridement · if the wound is left open to heal, standard precautions and clean technique are adequate for dressing changes.

🧿 Avascular necrosis

Circulation to the fracture site is disrupted, and the ischemia kills bone tissue. Common in hip fractures and fractures with displacement.

Raises the risk

Long-term corticosteroid use
Radiation therapy
Rheumatoid arthritis
Sickle cell disease

Treatment may require a bone graft or prosthetic replacement.

🧠 Complex regional pain syndrome (CRPS)

A chronic pain condition after injury, with pain out of proportion to what happened, plus autonomic changes in the limb — swelling, temperature and color changes, sweating, hypersensitivity to touch, and eventually muscle atrophy and joint stiffness.

✅ NursingEarly mobilization and physical therapy · multimodal pain management · protect the limb from cold and from unnecessary touch · expect referral to a pain specialist. Treat the pain as real — dismissing it makes the outcome worse.

🧶 Osteoarthritis & low back pain core content

OA vs RA is a guaranteed comparison question. Low back pain is a teaching question.

🧶 Osteoarthritis (degenerative joint disease)

🖼️ Osteoarthritis & total knee replacementTap to open it full size

What it is: progressive deterioration of articular cartilage. It is non-inflammatory (unless locally irritated) and non-systemic. Cartilage destruction outpaces repair, bone underneath erodes, osteophytes (bone spurs) form, and the joint space narrows.

	OSTEOARTHRITIS	RHEUMATOID ARTHRITIS
Process	Cartilage destruction with bone spurs at the joint ends — degenerative	Synovial membrane inflammation — inflammatory, autoimmune
Pain pattern	Pain with activity that improves with rest	Pain and stiffness that is worse in the morning, better with movement
Joints	Weight-bearing and used joints — asymmetric	All joints, symmetric — small joints of hands and feet first
Local signs	Effusions, localized inflammatory response	Swelling, redness, warmth
Systemic signs	None	Fever, fatigue, weight loss, anemia
Body size	Usually overweight	Usually underweight
Nodes	Heberden’s (distal interphalangeal) and Bouchard’s (middle interphalangeal)	Rheumatoid nodules, ulnar deviation, swan-neck deformity

⭐ Remember the HHeberden’s = Highest up the finger, at the end joint (distal). Bouchard’s = the Between joint (middle). Both are OA, not RA.

💉 OA management

Non-drug first

Weight loss — the single most effective thing for hip and knee OA
Heat for joint tenderness and stiffness (hot shower, moist heating pad)
Cold to reduce inflammation and numb nerve endings
Balance activity with rest; low-impact exercise; well-fitted supportive shoes
Joint-saving measures: good body mechanics, labor-saving devices, avoid repetitive strain (jogging, contact sports)

Drugs

Acetaminophen first — maximum 3,000 mg in 24 hr to prevent liver damage
NSAIDs for pain not relieved by acetaminophen or topicals — monitor liver and kidney function and CBC
Topical NSAID (diclofenac patch) is better tolerated — minimal systemic absorption
Intra-articular corticosteroid injections; limited number per joint per year
Herbals she may ask about: glucosamine, chondroitin, turmeric, ginger — check for interactions, especially with anticoagulants

Surgery when conservative measures fail → see arthroplasty below.

🦼 Low back pain

🕐 Acute vs chronicAcute: less than 4 weeks. Chronic: longer than 3 months, or repeated episodes.

Causes: muscle spasm or strain, ligament sprain, disk herniation or degeneration, spinal stenosis. It is a leading cause of missed work and disability.

Client teaching

Do not stay in bed — avoid prolonged bed rest and start gentle stretching as soon as possible
Ice for the first 48–72 hr, then heat
Lifting: bend at the knees, keep the back straight, hold the load close to the body, and never twist while lifting — get help with anything heavy or awkward
Avoid twisting the spine when changing position
Reach a healthy weight; stop smoking; manage stress
Low-heeled, comfortable shoes
Firm mattress; sleep side-lying with knees flexed, or supine with knees supported

🚨 Red flags to reportNew bowel or bladder incontinence or retention · saddle numbness · progressive leg weakness · fever with back pain. Those suggest cord or cauda equina involvement, not a strain.

🦴 Osteoporosis core content

Silent until something breaks. The exam questions are the DEXA score and the drug teaching.

📊 DEXA and the T-score

🖼️ OsteoporosisTap to open it full size

DEXA (dual-energy x-ray absorptiometry) is the screening test, usually of the hip or spine. A peripheral DEXA checks the heel, forearm or finger.

T-score compares her bone density to a young healthy adult
Z-score compares her to age-matched peers
Clothing stays on — metal objects come off (they interfere with the scan)
Painless, low radiation, she lies still on the table

Normal
≥ −1.0Osteopenia
−1.0 to −2.5Osteoporosis
≤ −2.5

T-score — more negative means less bone. A T-score at or below −2.5 with a fragility fracture is severe osteoporosis.

Other studies

pQUS (heel/tibia/patella ultrasound) — cheap, portable, low risk
Quantitative CT — predicts spine and hip fracture risk, more radiation than DEXA
Labs: CBC, ESR, calcium, phosphorus, alkaline phosphatase, vitamin D, creatinine, TSH; a 24-hr urine can measure calcium excretion

⚠️ Risk factors

Postmenopausal — estrogen loss speeds bone resorption
Advancing age; calcium absorption falls with age
Long-term corticosteroids — they suppress osteoblasts, cut calcium absorption, lower sex hormones
Low calcium and low vitamin D intake; little sun exposure
Excess caffeine — increases urinary calcium excretion
Alcohol — interferes with calcium and vitamin D and with liver handling of vitamin D
Smoking
High phosphorus intake — more than the recommended amount of cola-type soda raises calcium loss
Low body weight, sedentary life, prolonged immobility
Bariatric or gastric surgery — less calcium available
Family history; white and Asian ancestry; female sex assigned at birth

🍽️ Food and lifestyle teaching

Calcium-rich

Milk products
Green leafy vegetables
Fortified orange juice and cereals
Sardines and canned salmon with bones

Vitamin D–rich

Most types of fish
Egg yolks
Fortified milk and cereals
Time outdoors — skin makes vitamin D from sunlight

Also

Weight-bearing exercise — walking, resistance work
Stop smoking; limit alcohol and caffeine
Fall-proof the house — a prevented fall is a prevented fracture

Read food labels for calcium content. Very low protein intake also hurts — much of the body’s calcium is protein-bound.

💊 The drugs — and the one teaching point each

Drug / class	What it does	The teaching point they test
Bisphosphonates alendronate, ibandronate, risedronate, zoledronic acid, pamidronate	Reduce the number and action of osteoclasts, so less bone is resorbed	Early morning, empty stomach, 8 oz of water, stay upright 30 min. Report indigestion, chest pain, trouble swallowing or bloody emesis immediately — esophagitis and esophageal ulcers. Check with the provider before any dental procedure — risk of osteonecrosis of the jaw. Check calcium, vitamin D and renal function before starting.
Calcitonin	Decreases bone resorption and helps the kidneys clear excess calcium	Human calcitonin is subcutaneous only. Salmon calcitonin can be subcutaneous, IM or intranasal — alternate nostrils and watch for nasal irritation. Also used for hypercalcemia and Paget’s disease.
Teriparatide	A parathyroid hormone that stimulates osteoblasts to build new bone	Subcutaneous only. Limited to 2 years, then switch to a bisphosphonate. Orthostatic hypotension can occur for up to 4 hr after a dose — sit or lie down. Can cause hypercalcemia. Avoid with Paget’s disease, bone metastases, prior skeletal radiation, open epiphyses, or a history of skeletal cancer — osteosarcoma risk.
Raloxifene selective estrogen receptor modulator	Decreases osteoclast activity, so bone density rises	Contraindicated with a history of DVT or PE. Stop 72 hr before prolonged bed rest. Report calf pain or tenderness. Common effects: hot flashes, leg cramps, flu-like symptoms. Also reduces breast-cancer risk in postmenopausal women.
Denosumab RANKL inhibitor	Anti-resorptive — blocks osteoclast formation	Contraindicated in hypocalcemia — correct calcium first. Check for pregnancy before starting. Monitor calcium.
Estrogen ± medroxyprogesterone	Replaces estrogen lost at menopause	Give with progesterone if she still has a uterus — unopposed estrogen makes the endometrium grow. Contraindicated with breast or uterine cancer, DVT/PE, stroke or MI history, clotting disorders. Monthly breast self-exam.
Calcium carbonate / citrate	Supplements dietary calcium (supports bone — it does not by itself slow osteoporosis)	Give with food, in divided doses, with 6–8 oz water. Expect GI upset; watch for constipation and hypercalcemia.
Vitamin D	Increases calcium absorption from the gut so calcium is available to remineralize bone	Fat-soluble — toxicity is possible. Toxicity looks like confusion, apathy, agitation, irritability; abdominal pain, nausea, vomiting, constipation; polyuria, polydipsia, kidney stones. Severe hypercalcemia can cause dysrhythmias.

⭐ If you remember one thingBisphosphonate = water, upright, wait. Full glass of water, sit or stand for 30 minutes, nothing else to eat or drink until then.

🪝 Arthroplasty (joint replacement) high yield

Hip precautions and dislocation signs. Learn these as a set.

🪝 The vocabulary

Term	What is replaced
Total joint arthroplasty	All components of the joint
Total hip arthroplasty	Acetabular cup, femoral head, femoral stem
Total knee arthroplasty	Distal femoral component, tibial plate, patellar button
Unicondylar knee replacement	One compartment of the knee only
Hemiarthroplasty	Half the joint — e.g. only the femoral component for a femoral-neck fracture

Why: osteoarthritis, rheumatoid arthritis, osteonecrosis, trauma, congenital anomalies. Goal: eliminate pain, restore joint motion, improve function and quality of life.

What the client reports before surgery

Pain on weight bearing — walking, running
Joint crepitus and stiffness
Joint swelling, mostly in knees
Limited joint motion

🚫 Contraindications & risk raisers

Any active or recent infection — even a UTI. Organisms travel to the new joint and the prosthesis fails.
Bacteremia or sepsis; previous infection in that joint
Severe vascular dysfunction — it will not heal
Cannot follow the postoperative regimen
Abductor muscle weakness, dementia, neuromuscular disorders — joint instability and dislocation
Poor bone quality; advanced osteoporosis
Obesity — BMI over 40 raises superficial and deep infection, DVT, transfusion and failure rates
Smoking — badly impairs healing
Advanced age, especially over 75
Uncontrolled diabetes, heart disease, hypertension; unstable cardiac, renal or respiratory conditions
Malnutrition, hypoalbuminemia, anemia, ongoing opioid use → worse outcomes

Pre-op: CBC, urinalysis, electrolytes, BUN and creatinine, chest x-ray, ECG. Epoetin alfa may be given weeks ahead for mild anemia.

🚨 TOTAL HIP precautions

⭐ The three wordsAbduction. Neutral rotation. Limited flexion. Every hip rule comes from one of those three.

❌ Do not

Do not flex the hip more than 90°
Do not cross the legs
Do not internally rotate the toes
Do not sit in low chairs or chairs without arms
Do not turn onto the operative side unless the provider or policy allows it
Do not bend at the waist to reach the floor or put on shoes

✅ Do

Abduction pillow or a regular pillow between the legs in bed, and when turning to the unaffected side
Externally rotate the toes
Straight chairs with arms; raised toilet seat
Long-handled shoehorn, dressing stick, sock aid, reacher
Ice to the surgical site after ambulating
Supine with the head slightly elevated, affected leg neutral
Anticoagulation (warfarin, aspirin) may continue for several weeks

🚨 Dislocation — report immediatelyAcute onset of pain · she heard or felt a “pop” · the leg is internally or externally rotated · the leg looks shorter. Keep her still, keep the leg in alignment, and call the provider.

🦵 TOTAL KNEE — different rules

CPM machine (continuous passive motion) is often started right after surgery to keep the knee moving, promote circulation and prevent scar tissue. Follow the prescribed duration — turn it off during meals.
Avoid knee flexion positions that cause flexion contractures: no pillow behind the knee, no knee gatch in the mattress
Place one pillow under the lower calf and foot so the knee extends slightly — or let it rest flat
Pad slightly above the ankle to keep heels off the bed (pressure injury)
Medicate for pain so she can participate in early ambulation

🧠 Dislocation is uncommon after a knee replacementBut kneeling and deep knee bends are limited indefinitely.

✅ Discharge teaching, both jointsClean the incision daily with soap and water · watch for DVT (calf swelling, redness, pain), PE (shortness of breath, chest pain) and bleeding if on an anticoagulant · report fever or drainage · keep physical therapy appointments · tell every dentist and provider about the prosthesis.

Complications to watch for on either joint: dislocation, infection, anemia, neurovascular compromise, VTE. Older adults with chronic conditions are at higher risk.

🦵 Amputation core content

Positioning rules and phantom limb pain. Both are commonly missed.

🧠 Phantom limb pain vs. incisional pain

	Incisional pain	Phantom limb pain
What it is	Pain at the surgical site	Pain felt in the limb that is gone, from severed nerve pathways
Feels like	Localized surgical soreness	Deep and burning, cramping, tingling, shooting or aching
When	Immediately after surgery, improving daily	Immediately, up to several weeks later, or indefinitely
Who gets it	Everyone	More likely if she had chronic limb pain before the amputation; less common after traumatic amputation
Treatment	Analgesics, PCA pump	Treated completely differently: NSAIDs and acetaminophen are most common; antidepressants (amitriptyline, nortriptyline, desipramine); anticonvulsants (gabapentin, pregabalin). Mixed evidence for propranolol, ketamine, dextromethorphan, memantine, capsaicin, calcitonin.

⭐ The attitude questionThe pain is real. Acknowledge it and treat it. Any answer option that tells the client the limb is gone so the pain cannot be real is wrong. Non-drug options: TENS, mirror therapy, relaxation. Refer to a pain clinic if needed.

🧸 Positioning — the contracture rules

Lower limb

Do not put a pillow under the stump — it flexes the hip and knee and causes contractures
Above-the-knee amputation: use the prone position to keep the hip extended
Side-lying: keep the unaffected side down so the affected side is not abducted
Keep the pelvis horizontal to avoid a hip abduction contracture
Below-the-knee: avoid prolonged knee flexion — use a leg rest or board in the wheelchair to keep the knee extended
Stop elevating the limb 24 hr after a below-the-knee amputation — longer elevation causes hip and knee flexion contractures
Avoid prolonged sitting or wheelchair use

Upper limb

Avoid placing a pillow under the stump
Begin joint range-of-motion exercises about 7 days after surgery to prevent contractures

🧷 Residual limb (stump) care

Inspect every area of the stump daily — use a mirror if she cannot see it all
Wash with mild soap and water, rinse, and dry thoroughly; no lotions or powders inside the socket unless prescribed
Deep friction massage vertically around the incision as directed — it prevents adherent scar tissue
Figure-eight elastic wrap, up to 3 times daily — shapes and shrinks the limb without cutting off blood flow the way a circular wrap does
Check the skin every time the bandage comes off
A shrinker sock is easier for her to apply than a wrap
An air splint protects and shapes the limb and lets you see the wound
Limb-strengthening exercises as prescribed

🚨 ReportHeat in the stump (infection) · increasing redness, drainage or odor · wound edges separating · delayed healing. Compare pulses with the other extremity.

🚑 Post-op priorities

1Hemorrhage

Monitor the dressing and drainage. Keep a tourniquet at the bedside for a traumatic or emergent amputation.

2Perfusion

Assess warmth and color at the end of the residual limb; compare pulses side to side.

3Pain

Sort out incisional vs phantom, and treat each correctly.

4Mobility

Range of motion early, positioning to prevent contractures, prosthetic training.

5Grief

Body-image loss is real. Expect grieving; offer counseling and peer support.

🧠 Two closure typesA flap closure has skin sutured over the end of the residual limb. An open (guillotine) amputation leaves the flap unsutured so infection can drain — used when infection is present, closed later.

🔢 Dosage math you will see with this module on the exam

The final has math. These are the shapes it takes on an orthopedic unit.

🔢 Work each one, then open the answer

1 — Weight-based enoxaparin

A client weighs 176 lb. Enoxaparin 1 mg/kg subcutaneous is prescribed. How many mg per dose?

Show the work

176 ÷ 2.2 = 80 kg → 80 kg × 1 mg/kg = 80 mg

Convert pounds to kilograms first. Every single time.

2 — Morphine from a vial

Morphine 4 mg IV is prescribed. The vial reads 10 mg/mL. How many mL do you give?

Show the work

(4 mg ÷ 10 mg) × 1 mL = 0.4 mL

Desired over have, times the quantity.

3 — IV rate in mL/hr

1,000 mL of lactated Ringer’s over 8 hr. Rate?

Show the work

1,000 ÷ 8 = 125 mL/hr

4 — Drops per minute

Infuse 150 mL over 30 min with tubing at 15 gtt/mL. gtt/min?

Show the work

(150 mL × 15 gtt/mL) ÷ 30 min = 75 gtt/min

Volume × drop factor ÷ minutes. Round drops to a whole number.

5 — Acetaminophen ceiling

Acetaminophen 650 mg every 6 hr is scheduled, and she also takes a combination product with 325 mg twice a day. Is she over the limit?

Show the work

Scheduled: 650 × 4 = 2,600 mg. Combination: 325 × 2 = 650 mg. Total 3,250 mg — over the 3,000 mg/24 hr limit. Hold and call the provider.

This is the classic hidden-acetaminophen question. Always add the combination products in.

6 — Traction weight check

Skeletal traction is prescribed at 20 lb. You find 15 lb hanging and 5 lb resting on the floor. What do you do?

Show the answer

Reposition the weights so all 20 lb hang freely. If you cannot correct it, notify the provider. Do not remove weight to make it “hang right.”

❓ Quick-recall quiz test yourself

18 questions. Answer in your head first — the reason matters more than the letter.

1. A nurse is caring for a client who has a long leg cast applied 6 hr ago for a tibial fracture. Which finding should the nurse report to the provider first?

AReport of pain rated 6 on a scale of 0 to 10
BNumbness and tingling of the toes
CMild swelling of the toes
DItching under the cast

Show the answer

Answer: B

Paresthesia is the earliest sign of compartment syndrome and points to nerve compromise. Pain of 6 with an ordered analgesic, mild swelling and itching are all expected at 6 hr.

2. A nurse is assessing a client 18 hr after an open reduction of a femur fracture. The client is dyspneic, confused, has a heart rate of 118/min, and has petechiae across the chest and neck. Which complication should the nurse suspect?

ADeep vein thrombosis
BFat embolism syndrome
CCompartment syndrome
DOsteomyelitis

Show the answer

Answer: B

Fat embolism appears 12–48 hr after a long-bone fracture. The petechiae on the neck, chest, upper arms and abdomen are what distinguish it from a pulmonary embolism.

3. A nurse suspects compartment syndrome in a client who has a casted forearm fracture. Which actions should the nurse take? Select all that apply.

ANotify the provider immediately
BElevate the arm above the level of the heart
CLoosen the dressing or prepare for the cast to be bivalved
DApply an ice pack directly over the cast
EKeep the extremity at the level of the heart
FPrepare to assist with a fasciotomy

Show the answer

Answer: A, C, E, F

Elevating above the heart and applying cold both reduce arterial flow to a limb that is already ischemic. Keep it at heart level, relieve the constriction, notify the provider, and be ready for the fasciotomy.

4. A nurse is caring for a client in skeletal traction. Which action should the nurse take?

ARemove the weights while repositioning the client
BEnsure the weights hang freely at all times
CRest the weights on the bed frame when the client sleeps
DAdd weight if the client reports increased pain

Show the answer

Answer: B

Weights hang free or the traction is not working. Never lift, remove or rest them, and never change the amount — that is a prescription.

5. A nurse is teaching a client who has an external fixation device. Which statement indicates understanding?

A“I will expect white drainage around the pin sites.”
B“I will use a separate cleansing swab for each pin.”
C“I will tighten the pins if they become loose.”
D“I will pick off crusts that form around the pin site.”

Show the answer

Answer: B

One swab per pin prevents cross-contamination between sites. Drainage should be reported, loose pins are reported and not tightened by the client, and crusts are managed per protocol, not picked off.

6. A nurse is caring for a client with a wet plaster cast. Which action is appropriate?

AHandle the cast with the fingertips to check firmness
BCover the cast with a blanket to speed drying
CSupport the cast on a cloth-covered pillow
DPlace the casted leg directly on the bedside table edge

Show the answer

Answer: C

Handle a wet plaster cast with the palms — fingertips leave dents that become pressure points. Let warm dry air circulate rather than covering it, and use a cloth pillow instead of plastic.

7. A nurse is teaching a client following a total hip arthroplasty. Which instructions should the nurse include? Select all that apply.

AUse a raised toilet seat
BSit in low, soft chairs to reduce strain
CKeep a pillow between the legs when turning
DCross the legs at the ankles only
EAvoid bending the hip more than 90 degrees
FPoint the toes outward rather than inward

Show the answer

Answer: A, C, E, F

Everything traces back to abduction, neutral rotation, limited flexion. Low chairs force flexion past 90°, and crossing the legs — at the knees or the ankles — adducts the hip.

8. Four hours after a total hip arthroplasty, a client reports sudden severe hip pain and says she heard a pop. The affected leg appears shorter and is externally rotated. What should the nurse do first?

AReposition the client onto the operative side
BPerform passive range of motion to the hip
CKeep the client still, maintain leg alignment, and notify the provider
DAdminister the ordered analgesic and reassess in 1 hr

Show the answer

Answer: C

That is prosthetic dislocation. Immobilize, keep alignment, and get the provider — moving the joint or medicating and waiting can damage nerves and vessels.

9. A nurse is caring for a client with a continuous passive motion machine after a total knee arthroplasty. Which action is correct?

APlace a pillow under the knee while the CPM is off
BTurn the CPM off during meals
CIncrease the flexion setting if the client tolerates it well
DDiscontinue the CPM if the client reports discomfort

Show the answer

Answer: B

Turn it off for meals, follow the prescribed duration, and never change the flexion setting yourself. A pillow behind the knee causes a flexion contracture — put it under the calf and foot instead.

10. A nurse is teaching a client about newly prescribed oral alendronate. Which statement indicates understanding?

A“I will take it at bedtime with a snack.”
B“I will take it with a full glass of water and stay sitting up for 30 minutes.”
C“I will crush the tablet if it is hard to swallow.”
D“I will take it with my calcium supplement for better absorption.”

Show the answer

Answer: B

Early morning, empty stomach, 8 oz of water, and upright 30 minutes — that is what prevents esophagitis and esophageal ulcers. Calcium and food block absorption.

11. A client taking teriparatide reports feeling dizzy when standing after the injection. Which response by the nurse is correct?

A“That is not related to the medication.”
B“Sit or lie down when this happens — it can occur for up to 4 hours after a dose.”
C“Stop the medication and call the clinic in the morning.”
D“Take the injection with food to prevent it.”

Show the answer

Answer: B

Orthostatic hypotension can occur for up to 4 hr after teriparatide. It is expected, so teach safety rather than stopping the drug on her own.

12. A nurse reviews the record of a client scheduled for a total knee arthroplasty. Which finding should the nurse report as a contraindication?

AAge 55 years
BBody mass index of 27
CUrinary tract infection being treated with antibiotics
DHistory of a knee arthroscopy 3 years ago

Show the answer

Answer: C

An active infection anywhere — including a UTI — can seed the new joint and cause the prosthesis to fail. Surgery waits until it is cleared.

13. A nurse is caring for a client 1 day after a below-the-knee amputation. Which action should the nurse take?

AKeep the residual limb elevated on two pillows continuously
BDiscontinue elevation of the limb after 24 hr
CPlace the client prone for 30 min three times daily
DBegin figure-eight wrapping on postoperative day 7

Show the answer

Answer: B

Elevation past 24 hr after a below-the-knee amputation causes hip and knee flexion contractures. The prone position is the rule for above-the-knee amputations.

14. A client 3 weeks after an above-the-knee amputation reports burning, cramping pain in the missing foot. Which response is most appropriate?

A“The foot is gone, so the pain cannot be coming from there.”
B“This is phantom limb pain. It is real, and we treat it differently — let’s look at your options.”
C“This means your incision is infected.”
D“Try to distract yourself and it will pass.”

Show the answer

Answer: B

Phantom limb pain is real pain from severed nerve pathways. It responds to antidepressants and anticonvulsants, TENS and mirror therapy — not the same approach as incisional pain.

15. A nurse is caring for a client who has osteomyelitis of the tibia after an open fracture. Which statement should the nurse include in discharge teaching?

A“Antibiotics will continue for at least 4 to 6 weeks.”
B“Stop the antibiotic once your pain is gone.”
C“Airborne precautions are needed during wound care.”
D“Numbness below the wound is expected.”

Show the answer

Answer: A

Bone infection needs a long course — at least 4 to 6 weeks of IV and oral antibiotics. Relief of pain does not mean the infection is gone, standard precautions are adequate for an open wound, and new numbness is always reported.

16. A nurse is assessing an older adult who has an infected surgical wound over the femur. Which finding is least reliable for detecting infection in this client?

AElevated temperature
BIncreased WBC count
CErythema at the site
DElevated ESR

Show the answer

Answer: A

Older adults often do not mount a fever with osteomyelitis or other infections. Trust the local signs and the labs over the temperature.

17. A nurse is teaching a client who has osteoarthritis of the knees. Which statements should the nurse include? Select all that apply.

ALosing weight reduces stress on the knees
BTake no more than 3,000 mg of acetaminophen in 24 hours
CMorning stiffness lasting several hours is expected with this disease
DApply heat for stiffness and cold for swelling
EChoose supportive, well-fitted shoes
FJogging daily will rebuild the cartilage

Show the answer

Answer: A, B, D, E

Prolonged morning stiffness is a rheumatoid arthritis pattern; OA pain comes with activity and eases with rest. High-impact exercise like jogging worsens joint degeneration.

18. A nurse is teaching a client with acute low back pain. Which instruction is correct?

A“Stay on bed rest for a week.”
B“Apply heat for the first 3 days, then switch to ice.”
C“Bend your knees and hold the load close to your body when lifting.”
D“Twist at the waist rather than moving your feet when you turn.”

Show the answer

Answer: C

Lift with the legs, back straight, load close, no twisting. Avoid prolonged bed rest, and use ice for the first 48 to 72 hr, then heat.

✅ Your blueprint checklist from the key concepts doc

Straight from your NUR198 Final Exam Key Concepts list. Tick each one when you can teach it out loud.

Module 13 topics — the new content

Assessment of musculoskeletal function, including neurovascular assessment

Non-fracture musculoskeletal injury

Fractures, including hip fractures

Casts

Compartment syndrome

Skeletal traction

Skin traction

Pin care

Osteomyelitis

Osteoarthritis

Orthopedic surgery

Fat embolism syndrome

Avascular necrosis

Joint injury

Joint arthroplasty

Osteoporosis

Amputation

For every disorder on the final, be able to say

Pathophysiology

Diagnostic procedures and tests

Clinical manifestations

Medical management

Nursing management and priorities of care

Client teaching and education

Also on the exam

Math and dosage calculation problems

NGN-style questions

⭐ How to use thisDo not re-read. Say it out loud without looking, then tick the box. If you cannot say it, that is the topic to study — not the ones you already know.

All 12 of them in one place. Tap any picture, then use the arrows to walk through the set.