Week 13 — Musculoskeletal Guided Notes

By the end of today's lecture, I should be able to…

• ☑ Explain common musculoskeletal disorders. Osteoarthritis, osteoporosis, fractures and their complications, amputation.
• ☑ Develop a nursing plan of care. Pain control, mobility, neurovascular monitoring, infection prevention, and safety/fall prevention.
• ☑ Recognize fracture complications. Compartment syndrome, fat embolism syndrome, VTE, osteomyelitis, avascular necrosis, CRPS, and failures of bone healing.
• ☑ Apply nursing care to a client with an amputation. Hemorrhage first, then positioning to prevent contractures, phantom limb pain, and rehabilitation.

The single question that runs the whole module: "Is blood and nerve supply still reaching the tissue past the injury — and is that changing?"

Think First…

Mrs. Garcia is 72. "My knees hurt after I clean the house, but after I sit down for a while they feel much better." Which disorder does this sound MOST like?

• A. Rheumatoid arthritis
• B. Osteoarthritis
• C. Osteoporosis
• D. Gout
• Answer: B — Osteoarthritis. Pain that comes on with use and is relieved by rest is the signature of mechanical, wear-and-tear joint disease. A is wrong because RA hurts most after rest and loosens up with movement, with >60 min of morning stiffness and systemic symptoms. C is wrong because osteoporosis is painless until a bone breaks. D is wrong because gout is a sudden, exquisitely painful, hot red joint — classically the great toe — not activity-related aching.

What is Osteoarthritis?

• OA is a degenerative (non-inflammatory) joint disorder — the most common form of arthritis disorder.
• Instead of inflammation destroying the joint… OA is caused by progressive mechanical breakdown and loss of articular cartilage from years of load, repetitive stress and joint injury. Any inflammation present is secondary to the damage, not the cause of it.

Complete the picture

ATI Pearl

• OA is usually limited to the affected joint(s) only — localized, often asymmetric, and concentrated in weight-bearing joints (knees, hips, lumbar/cervical spine) plus the hands.
• Unlike rheumatoid arthritis, OA does NOT usually cause systemic symptoms — no fever, no profound fatigue, no weight loss, no anemia, no organ involvement. OA is a joint problem; RA is a whole-body autoimmune disease that shows up in joints.

Stop & Think

If the cartilage is wearing away, why would movement make the pain worse?
Because cartilage is the shock absorber. Once it is gone, every step loads raw bone against raw bone, and the exposed subchondral bone is richly supplied with pain fibers. Movement also drags inflamed synovium and bone spurs across the joint. Rest unloads the joint, which is exactly why the pain eases when she sits down.

Risk Factors — why does each one increase the risk?

Diagnostics

The provider orders an x-ray of the affected joint. Why?
Because x-ray shows the structural damage that defines OA: joint space narrowing, osteophytes (spurs), subchondral sclerosis, and cysts. There is no blood test that diagnoses OA — ESR, CRP, RF and anti-CCP are drawn only to rule out RA, and in true OA they are normal or negative.

Clinical Manifestations — complete the story

Match the finding — what does each tell you?

Riddle 🧩

"I disappear a little every year. When I'm gone… your bones begin arguing." Who am I?
Articular cartilage.

Nursing Management

The goal is NOT to cure OA. The goal is to…

• ✔ Control pain — scheduled acetaminophen (first-line; max 3 g/day, and 2 g/day or less in older adults or liver disease), topical NSAIDs or capsaicin, oral NSAIDs with food and GI caution, intra-articular corticosteroid injections, duloxetine for chronic pain. No DMARDs or biologics — those are RA drugs, and OA is not autoimmune.
• ✔ Improve mobility and function — low-impact exercise (walking, swimming, cycling), quadriceps strengthening for knee OA, ROM daily, PT referral
• ✔ Maintain independence and joint protection — weight loss, assistive devices (cane held in the hand opposite the affected leg), raised toilet seats, jar openers, splints, and balancing activity with rest

Heat or Cold?

Therapeutic Procedures

When medications no longer control symptoms… → Joint arthroplasty (total joint replacement) becomes an option. Indications: pain at rest and at night, loss of function, and failure of conservative therapy.

Before Surgery — match the test to its purpose

If you learn one table this week, learn this one. Every stem gives you the clue in the first sentence: better with rest = OA. Better with movement = RA.

Hip Arthroplasty

The BIG complication we are preventing is DISLOCATION of the prosthesis — the new femoral head can pop out of the acetabular cup before the surrounding capsule and muscle heal (roughly the first 6–12 weeks). The other two we watch for are VTE and infection.

Never… (posterior approach precautions)

• Cross your legs or ankles — no adduction past the midline of the body. Keep an abduction pillow between the legs in bed and when turning.
• Bend greater than 90 degrees at the hip — no low chairs, no low toilets, no leaning forward to tie shoes or pick things up off the floor, no sitting with knees higher than hips. Use a raised toilet seat, a chair with arms, a reacher/grabber, a long-handled shoe horn and a sock aid.
• Turn onto the operative (affected) side — turn toward the unaffected side with a pillow between the legs, unless the surgeon prescribes otherwise. Also avoid internal rotation — keep toes pointed to the ceiling, never turned inward.
• Why? All three motions — flexion past 90°, adduction, and internal rotation — lever the prosthetic femoral head out of the socket. Combined, they are exactly how a posterior hip dislocates.

Complete the patho

Total Knee Arthroplasty (TKA) — the precautions are different ⭐

A knee has no dislocation precautions. The enemy of a new knee is a flexion contracture — a knee that will not straighten.

• NEVER place a pillow under the knee. A pillow under the knee holds it flexed and produces a flexion contracture within days — and a knee that cannot fully extend cannot bear weight for a normal gait. Support the whole leg or place the pillow under the heel/ankle to keep the knee straight.
• Goal ROM: Full extension (0°) first, then progressive flexion — about 90° by discharge and 120° long-term. A CPM machine or knee immobilizer may be prescribed; follow the surgeon's degree settings.
• Daily nursing: Ice the knee to reduce edema, ankle pumps and quad sets every hour while awake, early ambulation on post-op day 0–1, pain medicated before PT, and neurovascular checks distal to the knee.
• Same shared complications as the hip: VTE (enoxaparin + SCDs + early ambulation) and infection (fever, increasing pain, purulent drainage — a prosthetic joint infection often means the hardware comes out).

Think Like the ER Nurse

A client arrives after falling off a roof. The right leg is deformed and the client is screaming in pain. What are your FIRST priorities? Write the first 3 nursing actions.

• 1. ABCs and a rapid trauma survey. A fall from a roof is a multi-trauma — airway, breathing, circulation, and cervical spine immobilization come before the leg every single time. A screaming client has an airway; that is useful information.
• 2. Control bleeding and assess for shock — direct pressure over any bleeding, vital signs, IV access. A femur fracture alone can hide 1–1.5 L of blood in the thigh.
• 3. Neurovascular check distal to the injury, then immobilize the leg as it lies — pulse, color, temperature, sensation, movement, capillary refill. Splint including the joints above and below, then recheck neurovascular status after splinting.

The Goal of First Aid

The fracture itself is not your first priority. Your priority is to prevent further injury/tissue damage, protect the neurovascular structures (nerves, arteries and veins) and the skin, and maintain perfusion and alignment distal to the fracture.

Put the Steps in Order (1 = first, 6 = last)

• 1. Assess for bleeding — hemorrhage kills before a fracture does.
• 2. Cover open wounds with a sterile (moist saline) dressing — an open fracture is a direct road to osteomyelitis. Never push protruding bone back in.
• 3. Remove jewelry and constricting clothing — do it before swelling starts, or the ring becomes a tourniquet you cannot get off.
• 4. Splint the extremity, immobilizing the joints above and below, in the position found.
• 5. Begin neurovascular checks — and note you check circulation both before and after splinting; the splint itself can compress.
• 6. Apply ice and elevate — last, because it treats swelling, not survival. Ice is stopped the moment compartment syndrome is suspected.

Connect the Pathophysiology

Why Do We Check It? Finish the story.

• A fracture causes bleeding and edema into a closed fascial compartment.
• Swelling increases pressure inside that compartment — fascia does not stretch, so the volume has nowhere to go.
• Pressure decreases capillary blood flow (perfusion) to muscle and nerve.
• If untreated… Nerve and muscle tissue can die — nerve begins to suffer within about 30 minutes and is irreversibly damaged by 12–24 hours; muscle necrosis begins at 4–6 hours. The end result is a permanently clawed, useless limb (Volkmann contracture) or amputation.

The Nurse's Question

Every neurovascular assessment answers ONE question:
"Is blood still reaching the tissue distal to the injury, are the nerves still working — and is that better, the same, or worse than the last time I checked?"

A neurovascular check has no meaning as a single snapshot. Its whole value is the trend, and the comparison is always to the unaffected limb.

Fill in the Assessment — what does each item tell me?

• Pain tells me about tissue ischemia. Pain that is out of proportion to the injury, unrelieved by opioids, and worse when the toes/fingers are passively stretched means the muscle is starving. This is the earliest and most reliable warning of compartment syndrome.
• Movement tells me about motor nerve function and muscle viability. "Wiggle your toes for me." Loss of movement (paralysis) is a LATE sign — the nerve has already been ischemic for hours.
• Sensation tells me about sensory nerve function. Sensory nerves are the most oxygen-sensitive structure in the limb, so numbness, tingling and burning are EARLY — second only to pain. Compare both sides; ask about "pins and needles," not just "can you feel this."
• Color tells me about arterial inflow versus venous outflow. Pale/white = arterial supply is being cut off. Dusky, blue or purple = venous congestion, blood cannot get out.
• Temperature tells me about arterial perfusion. Warm blood is what keeps a limb warm; a cool extremity compared to the other side means flow is dropping.
• Capillary refill tells me about perfusion of the distal capillary bed. Normal is less than 3 seconds (under 2 is ideal). Press the nail bed of an exposed digit; sluggish refill is one of the first objective findings you can chart.
• Pulse tells me about arterial flow in the large vessel proximal to where I am palpating. Never wait for a pulse to disappear — pulselessness is the LAST of the 6 P's, and by the time it is gone the muscle has been dying for hours. Compare to the opposite limb and grade it.

Predict the Next Slide

If swelling continues to increase, what complication are we about to learn? Acute compartment syndrome.

ATI Trick — can you always palpate a pulse through a cast?

Answer: NO. A cast covers the pulse point, and swelling underneath makes an already-covered pulse impossible to feel. Windows may be cut, but you cannot count on one.

If NO, name 3 other ways to assess circulation:

• 1. Capillary refill of the exposed fingers or toes (<3 seconds), compared to the other side.
• 2. Color and temperature of the exposed digits — pink and warm vs pale, dusky, or cool.
• 3. Sensation and motor function — can she feel light touch and wiggle the digits? Plus Doppler ultrasound of the distal pulse and pulse oximetry on an exposed toe if you need objective proof.

Why Immobilize? Circle ALL that apply.

• ✅ Prevent further injury — stops sharp fragments from cutting nerves and vessels
• ✅ Promote healing — bone can only lay down callus if the ends stay still and touching
• ✅ Reduce pain — most fracture pain comes from fragment movement and muscle spasm
• ✅ Correct deformity — traction and reduction realign the bone; the device then holds that alignment
• ✅ Decrease movement — the entire point of the device
• ❌ Restore circulation — immobilization protects circulation, it does not restore it. A device applied too tightly does the opposite — it is the number one cause of iatrogenic compartment syndrome.

A fracture should NOT move because movement can… (check all that apply)

• ✅ Increase bleeding — fragments tear the periosteal and muscular vessels again
• ✅ Increase pain — periosteum is one of the most pain-sensitive tissues in the body
• ✅ Damage surrounding nerves and blood vessels — the injury that turns a fracture into an emergency
• ✅ Delay healing — motion disrupts the fragile callus and leads to delayed union or nonunion
• ❌ Improve circulation — movement of fracture fragments never improves anything

Complete the Story

Match the Device

Connect the Dots — complete the chain

Predict Before We Learn

A cast is applied AFTER swelling decreases. Why? Because a cast is a rigid, circumferential container. If it is applied while the limb is still swelling, the limb keeps growing inside a shell that cannot grow with it. A splint is used first precisely because it is open on one side and can accommodate edema.

Fiberglass vs Plaster — complete the chart

Why Use Your PALMS?

Fresh plaster casts should be handled with your palms and the flat of both hands, NOT your fingertips.
Why? Because wet plaster is soft and takes an impression of whatever presses on it. Fingertips leave dents; a dent on the inside of the cast becomes a fixed pressure point against the skin → pressure injury and skin breakdown under a cast you cannot see through. Also let it air dry uncovered on a pillow, elevate it, turn it every 1–2 hours, and never use a heat lamp or blow dryer on hot to speed drying — it burns the skin and dries the outside while the inside stays wet.

ATI "Gotcha"

"My cast itches so I used a ruler to scratch under it." The nurse should respond:
"I'm glad you told me — let me look at your skin, because anything you slide under the cast can scratch you or push the padding into a lump, and a wound in there can get infected without either of us seeing it." Then teach: never insert coat hangers, rulers, pencils, knitting needles, or powder/lotion into a cast. Do instead: blow cool air from a hair dryer down the cast, tap or scratch the outside of the cast over the itchy spot, and take an antihistamine if prescribed. Report any new odor, drainage stain, or hot spot — those suggest a wound or infection underneath.

What Should the Nurse Assess? (⭐ = PRIORITY)

• ⭐ Pain — especially pain that is escalating, unrelieved, or worse with passive stretch
• ⭐ Pulse — distal to the cast; use Doppler if you cannot palpate
• ⭐ Color — of the exposed digits, compared to the other side
• ⭐ Temperature — warm vs cool to the back of your hand
• ⭐ Sensation — numbness or tingling is an early nerve sign
• ⭐ Capillary refill — less than 3 seconds
•   Drainage — important, but it points to bleeding or infection rather than acute ischemia. Circle the stain, write the date and time on it, and watch whether it grows.
•   Odor — a foul or musty smell plus a warm "hot spot" on the cast means infection underneath — a later complication, not the first-24-hour priority.

The six starred items are the neurovascular check. They are the priority because they detect the emergency; drainage and odor detect the infection.

NGN Matrix — 6 hours after cast placement

Notice the pattern: with a fresh cast there is very little middle ground. Findings are either normal post-injury changes or they are a neurovascular emergency — which is why an NGN matrix on this topic loads the "immediate" column.

Connect the Dots

Why are neurovascular checks performed every hour after a new cast?
Because the nurse is trying to detect rising compartment pressure and early ischemia (the changing 6 P's) BEFORE irreversible nerve and muscle death — permanent loss of function, Volkmann contracture, or amputation occurs.

Think Like the Surgeon — when would a cast NOT be enough?

When the fracture is unstable, comminuted (shattered), or displaced and will not hold alignment; when it is an open fracture with soft-tissue loss, contamination or burns that need ongoing wound access; when the fracture extends into a joint; when there is vascular or nerve injury requiring repair; or when severe swelling makes a circumferential cast unsafe.

Match the Treatment

Pin Site Care — Why?

Pin site care — how

• Use sterile technique and the prescribed solution (commonly chlorhexidine, sometimes sterile normal saline).
• One swab per pin, one stroke away from the pin, then throw it away.
• Assess every pin every shift for redness, warmth, swelling, increasing pain, and purulent or foul drainage; take a temperature.
• Expected: a small amount of clear or serosanguineous (thin, pink) drainage and mild tenderness in the first 24–72 hours. Not expected: thick yellow/green drainage, spreading redness, escalating pain, fever.
• Never loosen the clamps, never use the frame as a handle, and do not massage the skin around the pins. Pad any sharp pin ends so they do not injure the other leg or the linens.

ATI Tip

Riddle 🧩

"I'm holding your bone together… but if bacteria travel down me, they can infect the bone itself." What am I?
A skeletal fixation pin (the pin of an external fixator or skeletal traction).

What's the Purpose? (check all that apply)

• ✅ Reduce muscle spasms — the steady pull fatigues the spasming muscle that is pulling the fragments out of place. This is the main reason for Buck's traction.
• ✅ Maintain alignment of the fracture until definitive fixation
• ✅ Realign bone fragments (reduction by steady pull)
• ✅ Prevent deformity and contracture
• ❌ Strengthen muscles — traction immobilizes; it does not build strength. Muscles actually weaken in traction, which is why isometric exercises and a trapeze are added.

Skin vs Skeletal Traction — complete the chart

⚠️ Traction rules that get tested every time

• WEIGHTS HANG FREE. They must never rest on the floor, on the bed, on the footboard, or be caught in the bed frame — a weight that is resting is a weight that is not pulling, so the traction is not working and the fracture loses alignment.
• NEVER lift, remove, or add traction weights unless there is a specific prescription — and skeletal traction is never removed at all. Lifting the weights even briefly lets the muscle spasm back and the fragments override.
• Ropes stay in the pulley grooves, knots are secure and not touching the pulley, and nothing rests on the ropes.
• Maintain the line of pull and countertraction — keep the client centered in the bed and in correct body alignment; countertraction usually comes from the client's own body weight, so the head of the bed stays low unless prescribed otherwise.
• Assess neurovascular status distal to the traction every hour at first, then per protocol, plus skin under the boot/straps and every pin site.
• Use a trapeze to lift for linen changes and toileting; that is exactly what it is for, and it also builds upper-body strength for crutch or walker use.

Predict the Next Section — 5 days in traction (check all that apply)

• ❌ Compartment syndrome — this is an early complication, usually within the first 24–48 hours of injury or casting. By day 5 the swelling has peaked and receded, so it is far less likely.
• ✅ Skin breakdown — pressure over the sacrum, heels and under the traction boot/straps; unrelieved pressure plus shear plus moisture
• ✅ Venous thromboembolism (VTE) — venous stasis from immobility plus the hypercoagulable state after trauma — Virchow's triad in one bed
• ✅ Atelectasis / pneumonia — shallow supine breathing and no cough → alveoli collapse and secretions pool. Incentive spirometry every hour while awake.
• ✅ Constipation — immobility slows peristalsis and opioids slow it further. Fluids, fiber, and a stool softener.
• ✅ Osteomyelitis — if this is skeletal traction, every pin is an open tract to bone. With pure skin traction (Buck's) there is no pin, so this risk does not apply.

Clinical Judgment Challenge — who do you see FIRST?

Who is your priority? Room 402. Why? Because pain that morphine cannot touch, in a limb that is turning pale and cool inside a new cast, is compartment syndrome until proven otherwise — and there are only about 4–6 hours before muscle necrosis becomes permanent.

Looking Ahead 👀

What complication do you suspect in Room 402? Acute compartment syndrome — which is exactly the next section.

Think Like an NCLEX Nurse

A fracture is rarely what harms the patient… It's the COMPLICATIONS that follow.

NCLEX Tip ⭐ Instead of memorizing diseases, ask yourself: "What is the nurse trying to prevent?" Every intervention in this module answers that question — hourly neurovascular checks prevent limb loss, early ambulation and enoxaparin prevent PE, sterile pin care prevents osteomyelitis, and early fracture fixation prevents fat embolism.

Which Complication? Match the assessment.

Acute vs Chronic — which happens FIRST?

Failure of Fracture Healing — connect the terms

Stop & Think

Why are older adults at greater risk for delayed healing?
Because everything healing depends on is diminished: reduced blood supply from atherosclerosis and PAD, fewer and less active osteoblasts, lower bone density to build on, poorer nutrition (protein, calcium, vitamin D, vitamin C), more comorbidities (diabetes, renal disease), and medications that suppress healing (corticosteroids, some NSAIDs, chemotherapy). Add smoking, which constricts vessels and starves the fracture site of oxygen.

Complex Regional Pain Syndrome (CRPS)

The story: The fracture heals… BUT… the pain persists, and gets worse instead of better — out of all proportion to the original injury and continuing long after the bone has united.

Match the findings — which body system is involved?

• ❌ Respiratory   ✅ Nervous   ❌ Endocrine   ❌ GI
• The NERVOUS system — specifically the autonomic/sympathetic nervous system. That is why the findings are such an odd mixture: burning pain (sensory nerve), temperature and color changes (sympathetic control of blood vessels), sweating (sympathetic control of sweat glands), plus muscle spasms, weakness, edema, shiny skin and hair/nail changes in the affected limb.
• Treatment: Aggressive early physical therapy and mobilization (the limb must keep moving), gabapentin or pregabalin, tricyclic antidepressants, topical agents, sympathetic nerve blocks, TENS, and psychological support. Prevention is early mobilization after any fracture.

Avascular Necrosis (AVN)

• Most common site: The head/neck of the femur (femoral head) after a femoral neck fracture or hip dislocation. Blood reaches the femoral head by retrograde flow through vessels that run along the neck — break the neck and you cut the supply. Also the scaphoid (wrist) and the talus (ankle), for the same reason.
• Who is MOST at risk? ✅ Femur neck fracture. ❌ Sprained ankle · ❌ Wrist strain · ❌ Tennis elbow — none of these break a bone or disrupt its blood supply; they are soft-tissue injuries.
• NCLEX: A client had a hip fracture repaired several months ago and now has increasing hip pain and decreased function. The nurse suspects: avascular necrosis of the femoral head. The classic pattern is insidious groin/hip pain, worse with weight-bearing, appearing months after the injury. MRI detects it earliest — plain x-ray stays normal for a long time.

Predict the Next Complication

This is the "don't miss" topic of the entire module. If you are asked who to see first on an orthopedic floor, this client is almost always the answer.

Riddle 🧩

"I'm not caused by the broken bone… I'm caused by everything trapped around it. The longer I stay, the more tissue dies. Who am I?"
Acute compartment syndrome.

Build the Pathophysiology

The 6 P's — explain WHY each occurs ⭐

• Pain — because ischemic muscle and nerve release pain mediators and the swollen compartment is stretched. The result is pain out of proportion to the injury, unrelieved by opioids, and worse when you passively stretch the muscles of that compartment (pull the toes upward, extend the fingers). Pain is the FIRST and most reliable sign — and pain on passive stretch is the single most specific one.
• Pallor — because arterial inflow to the skin and muscle is being compressed, so less oxygenated blood reaches the tissue → the limb looks pale, white, or dusky, and capillary refill slows past 3 seconds.
• Paresthesia — because sensory nerve fibers are the most oxygen-sensitive tissue in the compartment and complain first → tingling, "pins and needles," burning, then numbness. This is an EARLY sign — the first objective neurologic change, right behind pain.
• Paralysis — because prolonged ischemia destroys motor nerve conduction and the muscle itself. Inability to move the digits is a LATE sign and often means the damage is already permanent. Never wait for it.
• Poikilothermia — because warm arterial blood is what keeps a limb warm. With inflow reduced, the limb drifts toward room temperature and feels cool compared with the opposite side.
• Pulselessness — because compartment pressure has finally risen high enough to collapse the major artery. This is the LAST and least useful sign: a palpable pulse does NOT rule out compartment syndrome — the capillaries died hours earlier. If the pulse is gone, so is the muscle.

Which Comes First? Number them 1–6.

• 1. PAIN — earliest, out of proportion, worse with passive stretch
• 2. PARESTHESIA — the first neuro change; sensory nerves fail first
• 3. PALLOR — skin loses its color; capillary refill slows
• 4. POIKILOTHERMIA — the limb turns cool
• 5. PARALYSIS — late, and usually irreversible
• 6. PULSELESSNESS — last of all, and the least reliable

Memory hook: the P's arrive in the order the tissue fails — nerve pain first, nerve sensation second, skin perfusion third, temperature fourth, muscle/motor fifth, big artery last.

NGN Matrix — 8 hours after a tibia fracture. Does the finding SUPPORT compartment syndrome?

🚨 The Response — what the nurse does, in order

Why NOT Elevate Above the Heart? Complete the pathophysiology.

Do not confuse this with routine post-injury care. For an ordinary swollen fracture with intact perfusion, elevation above heart level is correct and helpful. The moment compartment syndrome is suspected, that rule flips.

Looking Ahead 👀

The provider says, "We need to take this client to surgery NOW." What procedure are we about to learn? A fasciotomy — it relieves the pressure, not the fracture.

The Surgeon Says… "This patient needs emergency surgery."

Wait — the fracture isn't worse. So why are we going to surgery?
Because we are not operating on the bone; we are operating on the container. The pressure inside the fascial compartment has exceeded what the capillaries can push against, and the only way to drop that pressure fast enough to save the muscle and nerve is to cut the fascia open. No medication lowers compartment pressure.

Finish the Story

After the fasciotomy — nursing care

• The wound is left OPEN and covered with moist sterile saline dressings (or a wound-vac) — closing it would rebuild the pressure you just released.
• Delayed primary closure or a skin graft in about 3–5 days, once the swelling resolves.
• Continue neurovascular checks, monitor for infection (a large open wound), and watch for rhabdomyolysis → AKI: dark/tea-colored urine, ↑CK, ↑potassium, falling urine output. Push IV fluids as prescribed.

Looking Ahead…

Pressure is relieved, but the client still has a fractured femur. What life-threatening complication can happen when fat escapes from the bone marrow? Fat embolism syndrome.

Build the Pathophysiology

Which Bones Put Clients at Highest Risk? (check all that apply)

• ✅ Femur — the single highest-risk bone; huge marrow volume
• ✅ Tibia — a long bone with marrow; common in trauma
• ✅ Pelvis — very high risk — large marrow-rich bone, often multiple fractures at once
• ❌ Radius — small marrow volume, low risk. Wrist and forearm fractures are not FES stems.
• ✅ Humerus — a long bone with marrow, so it counts — though the risk is well below the femur and pelvis

The setup is always: long bone or pelvis, and 24–72 hours after the injury or the surgical fixation.

Think Like a Nurse

The fracture occurred yesterday. Today the client suddenly becomes restless, short of breath, and confused. Which complication should you suspect FIRST?
Fat embolism syndrome. New restlessness and confusion in a young trauma patient is hypoxia until proven otherwise — and the timing (24–72 hr after a long-bone fracture) names the cause. Never chart new confusion as "the client is anxious" without checking a pulse oximeter.

The Classic Triad — explain WHY it happens

Compare These Complications — Compartment Syndrome vs Fat Embolism

Fat Embolism vs Pulmonary Embolism — the other pair they confuse ⭐

Why Are Orthopedic Clients at Risk? Complete the sequence.

All three legs of Virchow's triad are present in one orthopedic bed: stasis (immobility), endothelial injury (the fracture and the surgery), and hypercoagulability (the trauma response).

Which Clients Have the Highest Risk? (check all that apply)

• ✅ Hip fracture — among the very highest-risk conditions in all of medicine for VTE
• ✅ Total hip replacement — major surgery near large veins plus post-op immobility
• ✅ Femur fracture — massive vessel injury and prolonged immobility
• ✅ Bedrest for several days — pure venous stasis; the single most modifiable risk factor
• ❌ Walking three times daily — this is prevention, not risk. The calf pump is the best anticoagulant there is.

Prevention — the three things always ordered together

• Early ambulation — often the same day as surgery; plus ankle pumps and dorsiflexion exercises hourly while awake.
• Sequential compression devices (SCDs) and/or compression stockings — on whenever the client is in bed, off only for skin assessment.
• Pharmacologic prophylaxis — enoxaparin subcutaneously (or a DOAC, or low-dose warfarin). Give in the abdomen, at least 2 inches from the umbilicus; do not expel the air bubble and do not rub the site. Monitor platelets for HIT and watch for any bleeding.

Compare the Assessment

A client complains of calf pain. What makes you think DVT instead of compartment syndrome?

Looking Ahead… What OTHER complications does immobility increase? (check all that apply)

• ✅ Pressure injuries — reposition every 2 hours, offload heels and sacrum
• ✅ Pneumonia — incentive spirometer every hour while awake, cough and deep breathe
• ✅ Constipation — fluids, fiber, stool softener — opioids make it worse
• ✅ Muscle loss — isometric and active ROM exercises, PT, out of bed as soon as allowed
• ✅ Urinary stasis — promotes UTI and calcium stones; hydrate and get the client upright to void

These five plus VTE follow you through every Med-Surg unit. When a question asks "what does immobility cause," this is the list.

Think Pathophysiology

Assessment — circle the findings that concern you

• ✅ Fever — systemic sign that the infection has moved beyond local
• ✅ Bone pain — deep, constant, throbbing, worse with movement, and it does not follow the expected healing curve
• ✅ Purulent drainage — thick yellow/green, sometimes foul — the most alarming single finding
• ✅ Elevated WBC — with elevated ESR and CRP, which are also used to track response to treatment
• ✅ Redness at pin site — especially if it is spreading rather than a thin rim
• ✅ Warmth — local inflammatory heat over the site

Every one of these concerns you — together they are the definition of an infected pin site becoming osteomyelitis. Diagnosis: MRI is the most sensitive imaging (x-ray stays normal for 2–3 weeks); bone biopsy with culture is definitive. Treatment: long-term IV antibiotics for 4–6 weeks or longer, often at home through a PICC line, plus surgical debridement/sequestrectomy and sometimes hardware removal.

Clinical Judgment Challenge — rank these four clients

The ranking logic every time: Airway/breathing → imminent limb loss → risk of embolizing to the lung → infection → comfort.

Connect the Entire Unit 🧠 — complete the concept map

Think First… List three reasons an amputation might be necessary.

• 1. Peripheral arterial disease / chronic ischemia — tissue that can no longer be perfused becomes gangrenous. This plus diabetes accounts for the large majority of amputations in the US.
• 2. Diabetes with a nonhealing infected foot ulcer — neuropathy removes protective sensation, PAD removes blood flow, and hyperglycemia cripples the immune response.
• 3. Severe trauma — a crushed or mangled limb with irreparable vessel, nerve and soft-tissue destruction. Also: uncontrollable osteomyelitis, malignant bone tumor (osteosarcoma), and congenital deformity.

Complete the Story

Match the Cause

Positioning — predict before we learn

Why shouldn't a client keep the residual limb flexed on a pillow all day?
Because muscles held short become permanently short. Continuous hip or knee flexion causes the flexor muscles and joint capsule to contract, and within days the joint will no longer fully extend. A limb that cannot straighten cannot be fitted with a prosthesis or bear weight in a normal gait. Elevation is limited to roughly the first 24–48 hours for edema control — and even then, elevate the foot of the bed rather than propping the limb into flexion on pillows.

✅ What to do instead

• Keep the residual limb extended and flat when lying supine; do not place a pillow under the knee or between the thighs for long periods.
• Position the client PRONE for 20–30 minutes, 3–4 times a day (if tolerated) — this stretches the hip into extension and is the classic prevention for a hip flexion contracture.
• Active and passive ROM, strengthening of the arms and the remaining leg, and early PT.
• Apply the elastic shrinker/compression wrap as prescribed to shape and shrink the limb for the prosthesis; wrap in a figure-eight, more pressure distally than proximally.
• Inspect the residual limb daily for redness, blistering and breakdown; wash with mild soap and water and dry thoroughly; no lotions, oils or powders on the skin that meets the prosthetic socket.

Phantom Limb Pain

Think like a nurse. The client says, "My toes are burning." The limb was amputated yesterday. What is your FIRST response?
Acknowledge that the pain is real and assess it — location, quality, intensity, what makes it better or worse — then medicate per prescription and reassess. Phantom limb pain is a genuine neurologic phenomenon, not imagination and not a psychiatric symptom. Never say "that isn't possible" or "your leg is gone." Also rule out other causes of new pain: hemorrhage, infection, or ischemia at the surgical site.

Connect the Dots

💊 Treating phantom limb pain

Opioids alone often work poorly because the pain is neuropathic. Expect gabapentin or pregabalin, tricyclic antidepressants (amitriptyline), calcitonin, beta blockers for constant burning, and antispasmodics for cramping — plus non-drug therapy: mirror therapy, TENS, massage and desensitization of the residual limb, relaxation, and early prosthetic use.

Rehabilitation — the goal

The goal after amputation is not simply wound healing. The goal is to maximize…

• ✔ Independence and function — safe transfers, mobility with a prosthesis or wheelchair, and return to ADLs
• ✔ Mobility and prosthetic use — which depends entirely on preventing contractures and shaping the residual limb well
• ✔ Psychosocial adjustment and quality of life — grief work, body image, sexuality, return to work and roles, peer support groups

Which team member?

Looking Ahead…

One reason older adults fracture more easily is because of another disease. Which one? Osteoporosis.

Think First…

Two clients fall from standing height. Client A has no injuries; Client B fractures a hip. Why?
Because Client B's bone is porous and structurally weak. Healthy bone absorbs the force of a fall from standing; osteoporotic bone has lost so much mineral density and trabecular architecture that the same force exceeds its breaking strength. That is a fragility fracture — a break from a force that should not break a bone. Common sites: hip, vertebrae, and distal radius (Colles fracture).

Complete the Story

Risk Factors — circle every client at increased risk

• ✅ 82-year-old woman — age plus postmenopausal estrogen loss; the highest-risk demographic
• ✅ Long-term corticosteroid therapy — the most important drug cause of secondary osteoporosis
• ✅ Smoker — nicotine lowers estrogen, reduces blood supply to bone and is directly toxic to osteoblasts
• ✅ Sedentary lifestyle — without mechanical loading, osteoblasts are never signaled to build
• ✅ Low calcium intake — no raw material; the body then pulls calcium out of the skeleton to keep serum levels normal
• ✅ Early menopause — more years without estrogen's brake on osteoclasts
• ❌ Weight-bearing exercise — protective, not a risk. Walking, stair climbing, dancing and resistance training stimulate bone formation.

Also on the list: thin/small frame, white or Asian ancestry, family history, excess alcohol, excess caffeine or soda, low vitamin D, anorexia, hyperthyroidism and hyperparathyroidism, and drugs such as phenytoin, heparin, PPIs and aromatase inhibitors.

Long-term corticosteroids increase fracture risk because they suppress osteoblasts, increase osteoclast bone resorption, decrease calcium absorption from the gut, increase calcium loss in the urine, and reduce sex hormones — bone is lost fastest in the first 6–12 months of therapy, which is why anyone on chronic steroids gets calcium, vitamin D, and often a bisphosphonate along with a baseline DEXA. Steroids also cause muscle weakness, which increases falls.

ATI Connection

A client asks, "Why didn't I know I had osteoporosis?" The nurse responds:
"Osteoporosis is a silent disease — bone loss causes no pain and no symptoms at all until something breaks, or until you notice you have lost height or your upper back is rounding." That is exactly why screening DEXA is done on a schedule instead of waiting for symptoms — and why prevention starts decades before the first fracture.

Prevention — complete the chart

💊 Bisphosphonates — alendronate (Fosamax), risedronate, ibandronate

They work by shutting down osteoclasts, so resorption slows and density climbs. The administration rules exist for one reason: these drugs are caustic to the esophagus.

• Take first thing in the morning, on a completely empty stomach, before any food, drink or other medication.
• Swallow with a full glass (6–8 oz / about 240 mL) of PLAIN WATER — never coffee, juice, milk or mineral water, all of which bind the drug and block absorption.
• Remain fully upright — sitting or standing — for at least 30 minutes (60 minutes for ibandronate) and do not lie down. Because if the tablet sits in the esophagus it causes esophagitis, ulceration, and even perforation.
• Wait at least 30 minutes before eating or taking anything else, including calcium and antacids.
• Report immediately: new heartburn, chest pain, or painful/difficult swallowing (esophagitis); new thigh or groin pain (atypical femur fracture); and jaw pain or a non-healing dental extraction site (osteonecrosis of the jaw). Encourage a dental exam before starting therapy.
• Contraindicated if the client cannot sit or stand upright for 30 minutes, or has esophageal stricture/achalasia, active upper GI disease, hypocalcemia, or severe renal impairment. Correct calcium and vitamin D deficiency first.

Clinical Judgment

An 84-year-old with osteoporosis falls at home. She reports severe hip pain, and the affected leg is shortened and externally rotated.

• What injury should the nurse suspect FIRST? A hip fracture — most likely a femoral neck or intertrochanteric fracture. Shortening plus external rotation is the classic presentation: the muscles pull the distal fragment up and rotate it outward. Expect severe groin/hip pain, inability to bear weight, and possible bruising.
• What assessment takes priority? Neurovascular assessment of the affected leg — distal pulses, color, temperature, capillary refill, sensation and movement — because a displaced femoral fracture can compress or lacerate the femoral vessels and nerve, and it is also the setup for avascular necrosis. Do this alongside your ABCs and a check for other injuries (a fall in an 84-year-old means head injury, C-spine, and the question of why she fell — syncope, orthostasis, medications, arrhythmia). Then: immobilize as she lies, do not straighten or rotate the leg, control pain, keep her NPO for probable surgery, and anticipate Buck's traction and VTE prophylaxis.

Complete the Concept Map — for each disorder, write the nursing PRIORITY

Final NGN Prioritization Challenge — rank FIRST to LAST

Musculoskeletal Review Challenge — connect the patient to the disorder

What complication should the nurse suspect?

Prioritize the Patient — rank 1 (see first) to 4 (see last)

• 1. Client with a new cast reporting numb toes and severe pain — compartment syndrome, a limb-threatening emergency.
• 2. Client with a below-the-knee amputation requesting assistance to the restroom — a safety need. A new amputee has an altered center of gravity and high fall risk, and if no one comes she will try alone.
• 3. Client with osteoarthritis requesting acetaminophen — a time-sensitive comfort need, but nothing is deteriorating.
• 4. Client with an external fixator needing scheduled pin-site care — important routine care that can safely be performed later in the shift.
• Explain why you chose your first patient: Because severe pain plus numbness in a freshly casted limb means rising compartment pressure is already damaging nerve. Nerve and muscle die within 4–6 hours, and the damage does not come back — everything else on this list can wait an hour without harm.

Select All That Apply — new long-leg cast: which findings require immediate follow-up?

• ❌ Pain relieved after prescribed morphine — expected; ischemic pain does not respond to opioids, so relief is reassuring
• ✅ Toes are pale and cool — pallor + poikilothermia = failing arterial inflow
• ✅ Capillary refill is 5 seconds — should be under 3 seconds; distal perfusion is compromised
• ❌ Able to wiggle toes without difficulty — intact motor function is a normal, reassuring finding
• ✅ Increasing numbness — paresthesia progressing to anesthesia; ischemic sensory nerve
• ✅ Severe pain with passive movement of the toes — the hallmark early sign
• What complication are these findings most consistent with? Acute compartment syndrome.

Clinical Judgment (NGN style) — tibia fracture

Findings: pain 10/10 despite IV morphine · pain increases when the nurse passively extends the toes · foot is pale and cool · capillary refill 5 seconds · pedal pulse weak · client reports tingling.

• Part 1 — Which complication does the nurse suspect? ❌ Fat embolism · ❌ Osteomyelitis · ✅ COMPARTMENT SYNDROME · ❌ Venous thromboembolism
  Not FES — there is no respiratory or neurologic change. Not osteomyelitis — no fever, drainage or elevated WBC, and the timing is wrong. Not VTE — a DVT limb is warm, red and swollen with an intact neurovascular exam, not pale, cool and numb.
• Part 2 — Which findings support your answer? (SATA)
  ✅ Pain with passive movement · ✅ Tingling · ✅ Weak pulse · ✅ Severe pain despite medication · ✅ Cool, pale foot · ❌ Fever — not a feature of compartment syndrome; fever points to infection
• Part 3 — What is the priority nursing action? Notify the provider/surgeon immediately — this is a surgical emergency requiring fasciotomy. While waiting: position the limb at heart level (never above), remove any ice, loosen or remove constricting dressings and prepare for the cast to be bivalved, give oxygen, keep the client NPO, and continue neurovascular checks.

Build the Concept Map

Exit Ticket — without looking at your notes

• The first sign of compartment syndrome is PAIN — severe, out of proportion to the injury, unrelieved by opioids, and worse with passive stretch of the digits.
• A client with sudden confusion, respiratory distress, and petechiae after a femur fracture most likely has fat embolism syndrome.
• The priority assessment after a new cast is neurovascular status distal to the cast — the 6 P's, compared to the other limb and trended over time.
• The best test for osteoporosis is a DEXA scan (bone mineral density); osteoporosis is a T-score of −2.5 or lower.
• Phantom limb pain occurs because the severed nerve endings and their pathways continue to fire, and the brain — which still holds a sensory map of the missing limb — interprets those signals as pain coming from the part that is gone.

"Can You Teach It?" — one sentence each

• Osteoarthritis: Cartilage wears away from mechanical use, so bone rubs on bone — pain is worse with activity and better with rest, morning stiffness is under 30 minutes, and there are no systemic symptoms.
• Hip arthroplasty precautions: Do not flex past 90°, do not cross the legs past midline, and do not rotate the hip inward — because all three lever the new joint out of its socket.
• Compartment syndrome: Swelling inside a closed fascial compartment cuts off perfusion, causing pain out of proportion that opioids will not touch and that worsens with passive stretch — keep the limb at heart level, call the provider, and prepare for a fasciotomy.
• Fat embolism syndrome: Marrow fat escapes into the bloodstream 24–72 hours after a long-bone fracture and plugs the pulmonary capillaries, causing hypoxia, confusion and petechiae — the treatment is oxygen and support.
• VTE after orthopedic surgery: Immobility plus vessel injury plus a hypercoagulable trauma response makes a clot in a leg vein that can travel to the lung — prevent it with early ambulation, SCDs and enoxaparin, and never massage a suspected clot.
• Osteomyelitis: Bacteria enter through an open fracture, surgical wound or fixation pin and infect the bone itself, causing deep pain, fever and purulent drainage — it needs weeks of IV antibiotics and often surgical debridement.
• Phantom limb pain: The nerves that used to serve the limb keep sending signals and the brain still maps that limb, so the client genuinely feels burning or cramping in a part that is gone — validate it and treat it as neuropathic pain.
• Osteoporosis: Bone is broken down faster than it is rebuilt, so the skeleton becomes porous and silently fragile until a fall from standing height breaks a hip — diagnose with DEXA and prevent with calcium, vitamin D, weight-bearing exercise and fall-proofing.

🤖 Ask Claire: "Quiz me on musculoskeletal complications. Give me one unfolding case at a time — a fresh cast, a femur fracture at 36 hours, an external fixator with drainage, and a post-op hip replacement — and make me name the complication and my first nursing action before you tell me anything."

Case #1 — "Something Doesn't Feel Right" (Mr. Jackson)

26 years old · motorcycle crash yesterday · closed right tibia/fibula fracture · long-leg fiberglass cast applied 2 hours ago · morphine PCA · VS stable. The night nurse says, "Everything looked great when I left."

Before entering the room — the TOP 3 things you are already thinking about

• 1. Compartment syndrome. Young, high-energy trauma, tibia fracture, and a brand-new circumferential cast — this is the highest-risk combination in the entire module, and the first 24–48 hours is the window.
• 2. A baseline neurovascular check right now, so that every later assessment has something to be compared to. "Everything looked great" from the last shift is not a baseline I can trend.
• 3. Whether the pain is being masked. A morphine PCA can blunt ordinary fracture pain — so if pain is escalating despite the PCA, that is far more alarming than the number itself.

45 minutes later…

"The pain is getting worse." Pain 10/10 · received IV morphine 30 minutes ago · pain increases when you gently move his toes · toes cool · cap refill 5 sec · reports tingling · pedal pulse weak.

• STOP! What complication should immediately come to mind? ACUTE COMPARTMENT SYNDROME. Four of the 6 P's have appeared in 45 minutes and every one of them is trending the wrong way.

What is your FIRST nursing action? Write it as you would chart it.

Notify the provider/surgeon immediately (STAT) and stay with the client — while positioning the limb at heart level, removing any ice, and loosening constricting dressings.

Sample charting: 1045 — "Client reports right leg pain 10/10, increased from 8/10, 30 min after IV morphine. Pain markedly increased with passive extension of the right toes. Right toes cool and pale, capillary refill 5 sec (was 2 sec at 0900), reports tingling, right pedal pulse weak (was 2+). Long-leg cast intact, feels tight. Limb placed at heart level, ice removed, cast and dressings assessed for constriction. Orthopedic surgeon notified at 1045 of neurovascular changes; orders received for STAT bedside evaluation and compartment pressure measurement. Client kept NPO, O₂ 2 L NC applied, IV patent. Continuous neurovascular monitoring in progress. Client and family updated." — C. Arnold, SN

Reflection — how did this patient change?

• Beginning of shift: Stable and expected — pain 8/10 but untreated, toes pink and warm, refill 2 sec, motor intact, pulse 2+. The plan was comfort and monitoring.
• End of shift: A limb-threatening surgical emergency — pain 10/10 despite IV morphine, pain on passive stretch, toes cool, refill 5 sec, tingling, weak pulse. The plan became emergency fasciotomy.
• What clue changed your priority? The trend, not any single number — and specifically pain that escalated after opioids and reproduced with passive stretch. That is the finding that separates ordinary fracture pain from ischemic muscle, and it is why hourly neurovascular checks exist.

Case #2 — "He's Acting Different…" (Mrs. Brown)

68 years old · fell at home yesterday · right femur fracture · awaiting surgery this afternoon.

1030 assessment

The CNA says, "She just doesn't seem like herself." RR 32 · HR 122 · SpO₂ 86% · restless · confused · petechiae on chest.

• Which assessment finding made you stop? SpO₂ 86% with new confusion and restlessness. New altered mental status in a fracture client is hypoxia until proven otherwise — and the petechiae on the chest confirm the diagnosis.
• What complication is occurring? Fat embolism syndrome — the complete triad: respiratory distress, neurologic change, and non-blanching petechiae.
• Do not miss this: Trust the CNA. "She doesn't seem like herself" is a clinical finding, not small talk.

What happened FIRST? Number these.

• 1. Long bone fractured (the femur, yesterday)
• 2. Fat entered the bloodstream from the torn marrow
• 3. Pulmonary capillaries blocked by fat globules, with free fatty acids inflaming the alveolar membrane
• 4. Respiratory distress — tachypnea, tachycardia, SpO₂ 86%
• 5. Confusion — from cerebral hypoxia and fat in the cerebral microcirculation

Connect the Dots

Why did the patient become confused?
Because her brain is not getting oxygen. Fat globules blocked her pulmonary capillaries and inflamed the alveolar membrane, so gas exchange failed (SpO₂ 86%); on top of that, fat emboli reach the cerebral microcirculation directly. Cerebral hypoxia produces restlessness and agitation first, then confusion — which is why new restlessness in any hypoxic client is treated as an oxygenation problem, never as "just being difficult," and never with a sedative.

Case #3 — "The Hip Replacement" (Mrs. Lewis)

74 years old · post-op day 1 total hip replacement · pain controlled · walked yesterday · abduction pillow in place.

• Which complication is your biggest concern TODAY? Dislocation of the prosthesis — because she is newly mobile, feeling better, and about to start doing things for herself. (VTE is the close second, and infection is the third.)

The CNA comes to you… "She wanted to put on her own socks."

You walk in. She is leaning forward, hip flexed well over 90°, and crossing one leg over the other.

• What is your priority? Stop the movement immediately and reposition her — ease her back to upright, uncross the legs, restore neutral alignment with the abduction pillow, then assess for pain, leg length, rotation and ability to move the leg. Then teach the precautions and provide a sock aid, reacher and long-handled shoe horn.
• Why is this dangerous? She is performing all three dislocating motions at once — flexion past 90°, adduction across midline, and internal rotation. The capsule and muscles that normally hold the joint were cut during surgery and have not healed, so nothing is holding the prosthetic head in the socket except position.

While you're helping her… another CNA says, "Mr. Hall's calf is swollen."

Who do you see FIRST? Room 401 (hip patient bending over) or Room 402 (post-op knee replacement, calf warm, swollen, painful)?

Room 402 — the warm, swollen, painful calf. Explain: That is an actual DVT that can embolize to the lung and kill him; the hip client has a potential problem that you can neutralize in ten seconds by telling her to sit up straight and uncross her legs on your way out the door. Actual beats potential, and life beats limb. Correct Mrs. Lewis's position as you leave, then go directly to Mr. Hall: keep him on bedrest, do not massage the calf, notify the provider, and anticipate a venous duplex ultrasound and anticoagulation. Delegate the sock aid and the reinforcement teaching to no one — come back and do it yourself.

Bonus Clinical Judgment

The provider orders compression devices, early ambulation, and enoxaparin. What ONE complication are all three trying to prevent?
Venous thromboembolism (DVT and its consequence, pulmonary embolism). Each one attacks a different leg of Virchow's triad: SCDs and ambulation defeat venous stasis, and enoxaparin defeats hypercoagulability.

Ten minutes before shift change, four call lights go off at once. Rank them — and for each one, say what is happening, what your immediate priority is, and why they are ranked there.

Defend your answer in one line: airway and breathing beat limb, limb beats infection, and infection beats expected pain.

If you read nothing else the night before the exam, read this. The repetition is on purpose.

• 1. THE 6 P's, IN ORDER: Pain → Paresthesia → Pallor → Poikilothermia → Paralysis → Pulselessness. Pain is first and most reliable; pulselessness is last and least useful — a palpable pulse never rules out compartment syndrome. Always compare to the other limb and trend it.
• 2. COMPARTMENT SYNDROME = pain out of proportion, unrelieved by opioids, worse with PASSIVE STRETCH. Keep the limb at heart level — never elevate above the heart and never apply ice — loosen or bivalve the cast, notify the provider STAT, prepare for fasciotomy within 4–6 hours. Afterward watch for rhabdomyolysis → AKI (dark urine, ↑CK, ↑K⁺).
• 3. FAT EMBOLISM = 24–72 hours after a long-bone or pelvic fracture, with hypoxia + confusion/restlessness + petechiae on the chest, neck, axillae and conjunctivae. Oxygen is the priority. Respiratory distress appears first, petechiae last. Prevent it with early fracture stabilization — anticoagulants do not treat fat.
• 4. TRACTION: the weights hang FREE and are NEVER lifted, removed or rested on the floor. A weight on the floor = zero traction. Skin traction (Buck's) 5–10 lb, temporary, before hip surgery; skeletal traction 15–30 lb, continuous, pins through bone, needs pin care.
• 5. PIN SITES: one swab per pin, one stroke, then discard. Serosanguineous drainage in the first 24–72 hours is expected; purulent drainage + fever + increasing pain = osteomyelitis, which needs cultures and 4–6 weeks of IV antibiotics. Never use the fixator frame as a handle and never loosen the clamps.
• 6. CASTS: plaster dries in 24–72 hr and must stay dry; fiberglass dries in 15–30 min and is water resistant. Handle a wet cast with PALMS, not fingertips, and let it air dry uncovered. Nothing goes inside a cast — ever. Cool air from a hair dryer for itching. Neurovascular checks hourly at first; report a hot spot, foul odor, or a growing drainage stain.
• 7. TOTAL HIP: no flexion >90°, no crossing the legs (adduction), no internal rotation, and do not turn onto the operative side. Abduction pillow, raised toilet seat, reacher, sock aid. TOTAL KNEE: never put a pillow UNDER the knee — the goal is full extension, and a flexion contracture ruins the gait.
• 8. OA vs RA: better with rest = OA; better with movement = RA. OA is asymmetric, weight-bearing joints, stiffness <30 min, Heberden/Bouchard nodes, no systemic signs, acetaminophen first. RA is symmetric small joints, stiffness >60 min, +RF and +anti-CCP, systemic symptoms, methotrexate first.
• 9. OSTEOPOROSIS is silent until it breaks something. Diagnose with DEXA (T-score ≤ −2.5). Alendronate: first thing in the morning, empty stomach, full glass of PLAIN water, stay UPRIGHT 30 minutes, nothing to eat for 30 minutes — because it burns the esophagus. Calcium 1,200 mg/day in divided doses + vitamin D 800–1,000 IU/day + weight-bearing exercise + fall-proof the house.
• 10. AMPUTATION: hemorrhage is the priority for the first 24 hours (tourniquet at the bedside). Then no continuous pillow under the limb — prone 20–30 min three to four times a day to prevent a flexion contracture. Phantom limb pain is real; validate it and treat it as neuropathic pain with gabapentin, TCAs and mirror therapy.
• 11. VTE: never massage a suspected DVT. Bedrest, notify the provider, anticipate duplex ultrasound and anticoagulation. Prevent with early ambulation + SCDs + enoxaparin — all three attack Virchow's triad.
• 12. PRIORITIZATION ORDER for this whole unit: breathing (fat embolism / PE) → limb (compartment syndrome) → clot that can travel (DVT) → infection (osteomyelitis) → expected pain. When two clients look equally bad, ask which one loses something permanent first.