NLE Musculoskeletal Nursing — Fractures, Trauma and Orthopedic InjuriesCheat Sheet
A printable cheat sheet for Fractures, Trauma and Orthopedic Injuries, built for NLE reviewers who want one go-to reference in the final stretch. Covers formulas, key definitions, common question types, and the Professional Regulation Commission (PRC) — Board of Nursing-specific twists you will see on NLE day.
Exam context
For the Philippine Nurse Licensure Examination (PNLE), Professional Regulation Commission (PRC) — Board of Nursing tests Musculoskeletal Nursing under a "Core" label, with Fractures, Trauma and Orthopedic Injuries in the 2nd slot across 3 chapters. NLE candidates must clear the 75% weighted average with no sub-test below 60% cut on the 2026 paper, which draws about 50 Musculoskeletal Nursing questions. Date to watch: Bi-annual.
Fractures, Trauma and Orthopedic Injuries - Cheat Sheet
Your last-minute revision companion for mastering fracture types, bone healing stages, critical complications (FES and compartment syndrome), and emergency nursing interventions. This cheat sheet condenses everything you need to know for the NLE exam on musculoskeletal trauma.
Sections
Section Title
FRACTURE TYPES AND CLASSIFICATION
Important Facts
- OPEN FRACTURES = High risk of osteomyelitis and sepsis; cover with sterile dressing, control bleeding, assess neurovascular status, give antibiotics per protocol.
- GREENSTICK FRACTURES = Mostly in children (pliable bones); can still cause disability despite incomplete break.
- SPIRAL FRACTURES = Consider non-accidental trauma (NAT) if history inconsistent; report to authorities per RA 9173 and institutional protocol.
- COMMINUTED FRACTURES = Multiple fragments increase risk of malunion, nonunion, and neurovascular compromise.
- DISPLACED FRACTURES = Require reduction (closed or open) before healing can occur properly.
- Fracture healing depends on: blood supply, age, nutrition (protein, calcium, vitamin D), smoking status, diabetes, corticosteroid use, infection risk.
Key Definitions
Term
Fracture
Example
Motor vehicle accident causing femoral shaft fracture or osteoporotic hip fracture.
Definition
Break in bone continuity from trauma, disease (pathologic), or repetitive stress.
Term
Complete Fracture
Example
Transverse fracture of tibia.
Definition
Bone broken all the way through; fragments completely separated.
Term
Incomplete Fracture
Example
Greenstick fracture in children.
Definition
Bone partially broken; continuity not completely interrupted.
Term
Closed (Simple) Fracture
Example
Uncomplicated arm fracture without skin break.
Definition
Skin integrity intact; no communication with external environment.
Term
Open (Compound) Fracture
Example
Tibia fracture with protruding bone through skin.
Definition
Bone breaks through skin; HIGH INFECTION RISK (osteomyelitis, sepsis).
Term
Comminuted Fracture
Example
Crushing injury from machinery or high-speed accident.
Definition
Bone splintered into three or more fragments; associated with high-energy trauma.
Term
Greenstick Fracture
Example
Common in children; radius fracture with partial break.
Definition
Incomplete fracture; bone bends and cracks on one side (pliable bone).
Term
Spiral Fracture
Example
Humerus fracture from rotational force or child abuse.
Definition
Twisting fracture line around bone; raises suspicion of abuse if history does not fit.
Term
Transverse Fracture
Example
Femur fracture from direct blow.
Definition
Fracture line straight across bone perpendicular to long axis.
Term
Oblique Fracture
Example
Tibia fracture from shearing force.
Definition
Fracture line at an angle to long axis of bone.
Term
Impacted Fracture
Example
Hip (femoral neck) fracture in elderly from fall.
Definition
One bone fragment driven into another; compression fracture.
Term
Displaced Fracture
Example
Ankle fracture with visible deformity.
Definition
Bone fragments out of alignment; requires reduction for proper healing.
Term
Nondisplaced Fracture
Example
Stress fracture of metatarsal in runner.
Definition
Bone fragments remain aligned; usually managed conservatively.
Term
Pathologic Fracture
Example
Vertebral fracture from osteoporosis or bone cancer metastasis.
Definition
Fracture in bone weakened by disease (osteoporosis, tumor, infection, metastasis).
Diagrams To Know
- Types of fractures: complete vs incomplete, closed vs open, comminuted, greenstick, spiral, transverse, oblique, impacted.
- Displaced vs nondisplaced fractures: visual representation of alignment.
- Open fracture pathway: entry point through skin, contamination risk, need for immediate coverage and antibiotics.
Common Values
Value
First 1–3 days post-fracture
Symbol
Day 0–3
Quantity
Hematoma formation onset
Value
Within approximately 1 week
Symbol
Day 7
Quantity
Soft callus formation onset
Value
Weeks 2–6 post-fracture
Symbol
Week 2–6
Quantity
Hard callus formation peak
Value
4–16 weeks depending on bone and severity
Symbol
Variable
Quantity
Expected healing time (simple fracture)
Section Title
STAGES OF BONE HEALING (CRITICAL FOR NLE)
Important Facts
- SEQUENCE: Hematoma → Soft Callus → Hard Callus → Ossification → Remodeling (mnemonic: H-S-H-O-R).
- TIMELINE: Hematoma (days 1–3), Soft Callus (within 1 week), Hard Callus (weeks 2–6), Ossification (ongoing), Remodeling (months to years).
- FACTORS DELAYING HEALING: poor blood supply, infection, advanced age, poor nutrition (inadequate protein/calcium/vitamin D), smoking, diabetes, corticosteroid use, immobility.
- NONUNION RISKS: open fractures, comminuted fractures, displaced fractures, avascular bone segments, infection.
- MALUNION CONSEQUENCES: limb shortening, angular deformities, loss of range of motion, functional impairment.
- Nursing role: immobilize, elevate, ice initially, assess neurovascular status, promote nutrition and mobility, monitor for healing complications.
Key Definitions
Term
Hematoma Formation
Example
Blood collection around fractured femur within first 24 hours.
Definition
First stage (1–3 days): bleeding at fracture site forms clot; inflammation begins.
Term
Fibrocartilage (Soft) Callus Formation
Example
Granulation tissue forming around fracture site by day 7.
Definition
Second stage (within ~1 week): fibroblasts and chondroblasts bridge the gap; weak but flexible.
Term
Bony (Hard) Callus Formation
Example
X-ray showing callus formation by week 3–4.
Definition
Third stage (weeks 2–6): osteoblasts convert soft callus to woven bone; increasingly rigid.
Term
Ossification
Example
Woven bone gradually replaced by mature bone over weeks to months.
Definition
Fourth stage: callus matures into solid lamellar bone.
Term
Remodeling
Example
Callus gradually absorbed and replaced; bone returns to normal shape.
Definition
Fifth stage (ongoing over months to years): osteoblasts and osteoclasts reshape bone along stress lines, restoring original contour.
Term
Delayed Union
Example
Femur fracture taking 6 months instead of typical 4 months.
Definition
Fracture heals slower than expected but eventually heals; may take 3–6 months or longer.
Term
Nonunion
Example
Scaphoid (wrist bone) fracture with poor blood supply failing to heal.
Definition
Failure of fracture to heal; bone fragments do not unite; may require surgery.
Term
Malunion
Example
Radius fracture healing at an angle, causing wrist deformity and loss of rotation.
Definition
Fracture heals in deformed or misaligned position; results in functional or cosmetic problems.
Diagrams To Know
- Five stages of bone healing over time: diagram showing each stage and approximate timeline.
- Factors affecting bone healing: positive factors (young age, good blood supply, adequate nutrition, no smoking) vs negative factors (advanced age, poor blood supply, infection, smoking, diabetes).
Section Title
EMERGENCY AND INITIAL MANAGEMENT
Important Facts
- PRIMARY ASSESSMENT: ABCs first (airway, breathing, circulation) in trauma patient; fracture assessment is SECONDARY.
- SCENE MANAGEMENT: Immobilize in position found; splint joints above and below fracture; support injured limb during transfer.
- OPEN FRACTURE CARE: Cover wound with sterile dressing immediately; control bleeding; DO NOT push bone back; assess neurovascular status; administer antibiotics per protocol (typically within 3 hours); tetanus prophylaxis.
- NEUROVASCULAR ASSESSMENT: Perform before AND after splinting; assess color, temperature, capillary refill, pulses, sensation, motor function; document baseline.
- REDUCTION METHODS: Closed reduction (manual), open reduction (surgical with ORIF), or external fixation; choice depends on fracture type, severity, and clinical judgment.
- CAST AND TRACTION: Used after reduction to maintain alignment during healing (see next section for detailed care).
Key Definitions
Term
Immobilization
Example
Splint arm fracture at scene using newspaper or magazine before transport.
Definition
Keep fracture in position found before moving patient; prevent further injury and complications.
Term
Reduction (Closed)
Example
Realigning a wrist fracture using traction and manipulation under anesthesia.
Definition
Manual manipulation to restore bone alignment without surgical incision.
Term
Reduction (Open)
Example
Femur fracture requiring surgical repair with intramedullary rod.
Definition
Surgical reduction with visualization; uses ORIF (open reduction internal fixation) with plates, screws, or rods.
Term
Open Reduction Internal Fixation (ORIF)
Example
Complex ankle fracture fixed surgically with plates and screws.
Definition
Surgical approach: open fracture site directly, reduce, and stabilize with internal devices (plates, screws, rods, wires).
Term
External Fixation
Example
Severely contaminated open fracture or complex pelvic fracture initially managed with external fixator.
Definition
External metal frame with pins driven into bone above and below fracture; maintains alignment without surgery on fracture site.
Diagrams To Know
- Emergency fracture management flowchart: assessment → immobilization → transport → reduction → casting/traction.
- Neurovascular assessment checklist: 5 Ps (pain, pallor, pulses, paresthesia, paralysis) and CMS (circulation, motor, sensory).
Common Values
Value
First 24–48 hours above heart level
Symbol
24–48 hrs
Quantity
Recommended elevation duration for wet cast
Value
24–48 hours (can feel cool while drying)
Symbol
1–2 days
Quantity
Expected drying time for plaster cast
Value
Every 1–2 hours initially, then every 4–8 hours after drying
Symbol
q1–2h initially
Quantity
Frequency of neurovascular checks
Section Title
CASTS AND TRACTION MANAGEMENT
Important Facts
- WET PLASTER CAST CARE: Support with palms (not fingers) during drying; elevate limb above heart for first 24–48 hours; apply ice to reduce swelling; perform frequent neurovascular checks.
- DRY CAST CARE: Assess neurovascular status regularly; report pain, numbness, coolness, foul odor, or drainage; ensure no objects inserted into cast; monitor for pressure areas.
- TRACTION WEIGHTS: Hang freely; NEVER touch floor; if weight removed without order, fracture alignment is disrupted and healing is jeopardized.
- TRACTION ROPES AND PULLEYS: Keep ropes on pulleys; maintain countertraction (typically from patient's body weight); NEVER remove traction weights without specific provider order.
- SKELETAL TRACTION PIN CARE: Aseptic technique; clean around pin sites with sterile solution per protocol (typically normal saline or chlorhexidine); monitor for pin site infection (drainage, redness, warmth, pain); document drainage type/amount.
- PATIENT EDUCATION: Never insert objects into cast; report increasing pain, numbness, coldness, swelling, foul odor, or drainage; avoid weight-bearing unless permitted; maintain traction alignment; keep weights hanging freely.
- IMMOBILITY COMPLICATIONS: Risk of DVT/PE, pneumonia, constipation, skin breakdown; promote early mobilization, sequential compression devices, incentive spirometry, fluids, and nutrition.
Key Definitions
Term
Cast
Example
Full-leg cast for femur fracture.
Definition
Rigid external immobilization device (plaster or fiberglass) applied to immobilize reduced fracture and protect during healing.
Term
Traction
Example
Balanced skeletal traction for femur fracture: weights hang freely to maintain alignment.
Definition
Pulling force applied to limb to maintain alignment, reduce muscle spasm, and immobilize fracture; can be skeletal (pins in bone) or skin (adhesive straps).
Term
Skeletal Traction
Example
Skeletal traction for femur or tibia fracture.
Definition
Pins (Steinmann pins, Kirschner wires) placed directly in bone; allows greater traction force; requires aseptic pin-site care.
Term
Skin Traction
Example
Buck traction (skin traction with adhesive strap) for mild hip or knee fracture.
Definition
Adhesive straps or foam boots applied to skin; limited force; used for short-term immobilization or in children.
Diagrams To Know
- Cast and traction setup: diagram showing proper elevation, weight positioning, pulley system, and countertraction.
- Pin site care process: assessment → cleansing → observation → documentation.
Common Values
Value
24–72 hours
Symbol
Day 1–3
Quantity
Typical onset after fracture
Value
5–15%
Symbol
5–15%
Quantity
Mortality rate
Section Title
FAT EMBOLISM SYNDROME (FES) — CRITICAL COMPLICATION
Important Facts
- CLASSIC TIMING: Appears 24–72 hours post-fracture (NLE CLASSIC TEST ITEM).
- HIGH-RISK FRACTURES: Long bones (femur, tibia, humerus) or pelvis; mechanism: trauma → marrow fat enters bloodstream → pulmonary and cerebral emboli.
- CLASSIC TRIAD OF MANIFESTATIONS: (1) Hypoxemia (dyspnea, tachypnea, low SpO2), (2) Neurologic changes (confusion, restlessness, altered mental status, irritability, combativeness), (3) Petechial rash (chest, axillae, conjunctiva—classic sign).
- OTHER SIGNS: Fever, tachycardia, headache, nausea, vomiting, renal dysfunction.
- PATHOPHYSIOLOGY: Fat emboli → mechanical obstruction of capillaries → pulmonary edema, ARDS, cerebral edema.
- PRIORITY NURSING INTERVENTION: Administer OXYGEN immediately to correct hypoxemia; position with head of bed elevated; support respiratory and hemodynamic function; notify provider emergently.
- PREVENTION: Early immobilization of long-bone fractures; gentle handling during transfer and positioning; early mobilization when stable; prophylactic measures (oxygen, anticoagulants may be considered).
- DIAGNOSTIC CLUES: Tachypnea out of proportion to injury; confusion in alert patient; petechiae on chest/axillae/conjunctiva (not just dependent areas—distinguish from pressure-related rash).
- PROGNOSIS: Mortality 5–15%; survivors may have permanent neurologic sequelae; mortality higher in elderly.
- TREATMENT: Supportive care (oxygen, mechanical ventilation if needed), treatment of ARDS, monitoring for complications (DIC, renal failure).
Key Definitions
Term
Fat Embolism Syndrome (FES)
Example
Patient with femur fracture becomes confused, dyspneic, and develops petechial rash on day 2.
Definition
Fat globules from bone marrow enter bloodstream and lodge in lungs and brain; typically occurs 24–72 hours after long-bone or pelvic fracture; life-threatening.
Diagrams To Know
- Fat embolism pathophysiology: fracture → marrow disruption → fat release → venous entry → pulmonary/cerebral circulation → occlusion → manifestations.
- Clinical presentation timeline: fracture → 24–72 hours → hypoxemia, neurologic changes, petechiae.
Common Values
Value
4–6 hours
Symbol
4–6 hrs
Quantity
Time to irreversible damage
Value
0–10 mmHg
Symbol
0–10 mmHg
Quantity
Normal tissue pressure
Value
Greater than 30 mmHg (or within 30 mmHg of diastolic BP)
Symbol
>30 mmHg
Quantity
Pressure indicating compartment syndrome
Section Title
COMPARTMENT SYNDROME — SURGICAL EMERGENCY
Important Facts
- CRITICAL TIMELINE: Irreversible muscle and nerve damage occurs within 4–6 HOURS; recognition and action are URGENT.
- CAUSES: Internal swelling and bleeding (fracture, crush injury, reperfusion after tourniquet release) or external compression (tight cast, tight dressing, edema trapped by rigid circumferential dressing).
- THE 6 PS (CRITICAL TO KNOW): Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia.
- EARLIEST AND MOST RELIABLE SIGN: PAIN — severe, unrelenting, out of proportion to injury; WORSE ON PASSIVE STRETCH of fingers/toes (key finding); this is THE earliest warning.
- PAIN ON PASSIVE STRETCH: Test by gently extending/flexing fingers/toes of affected limb; if severe pain with passive movement (worse than with active movement), suspect compartment syndrome immediately.
- LATE SIGNS: Pulselessness, paralysis, profound sensory loss (do NOT wait for these—act on early signs).
- EMERGENCY NURSING ACTIONS: (1) NOTIFY PROVIDER IMMEDIATELY—this is a surgical emergency. (2) DO NOT elevate limb above heart level—reduces arterial flow and worsens ischemia. (3) DO NOT apply ice—reduces arterial perfusion. (4) Keep limb at heart level. (5) Remove or loosen tight cast/dressing immediately as ordered. (6) Prepare for emergency fasciotomy (surgical incision of fascia to release pressure). (7) Continue neurovascular checks and document carefully.
- WHY NOT ELEVATE?: Elevation increases venous return but decreases arterial inflow; in compartment syndrome, compromised arterial perfusion must be maintained—keeping limb at heart level is critical.
- FASCIOTOMY: Surgical incision of fascia to decompress compartment and restore perfusion; must be done urgently if pressure is not relieved; may require leave open and delayed closure.
- COMPLICATIONS OF UNTREATED COMPARTMENT SYNDROME: Rhabdomyolysis, myoglobinuria (dark urine), acute renal failure, loss of limb (amputation), death.
- PREVENTION: Avoid overly tight casts or dressings; elevate to heart level initially, then at heart level; monitor neurovascular status frequently; educate patient on warning signs.
Key Definitions
Term
Compartment Syndrome
Example
Severe tibial fracture with tight cast causing increased compartment pressure and limb ischemia.
Definition
Increased pressure within inelastic muscle compartment (bounded by fascia) compromises circulation and perfusion; irreversible tissue damage in 4–6 hours; TRUE EMERGENCY.
Diagrams To Know
- The 6 Ps of compartment syndrome: early signs (pain, pallor, paresthesia) vs late signs (pulselessness, paralysis, poikilothermia).
- Decision flowchart: suspect compartment syndrome → notify provider immediately → loosen cast/dressing → prepare for fasciotomy.
- Compartment anatomy: fascial compartments of forearm and leg; how increased pressure compromises vessels and nerves.
Common Values
Value
Months to years after fracture
Symbol
Delayed
Quantity
Typical timeline for AVN manifestation
Value
Up to 25% if untreated
Symbol
High
Quantity
Risk of PE with untreated DVT
Section Title
OTHER FRACTURE COMPLICATIONS
Important Facts
- DVT/PE PREVENTION: Early mobilization when stable; sequential compression devices; anticoagulant prophylaxis per protocol (enoxaparin, rivaroxaban); maintain hydration; leg exercises.
- DVT SIGNS: Unilateral leg swelling, pain, warmth, redness; positive Homan's sign (calf pain on dorsiflexion—though not highly specific).
- PE SIGNS: Sudden dyspnea, chest pain, tachycardia, hypoxemia, syncope; can be rapidly fatal.
- OSTEOMYELITIS RISK: Open fractures, contamination, inadequate antibiotics, poor wound care.
- OSTEOMYELITIS SIGNS: Fever, localized bone pain, drainage, elevated WBC and ESR.
- OSTEOMYELITIS TREATMENT: Culture, long-term antibiotics (weeks to months), sometimes surgical debridement.
- HEMORRHAGE MANAGEMENT: Monitor for hypotension, tachycardia, pallor, altered mental status; type and cross for transfusion; prepare for emergency surgery if needed; manage shock (fluids, oxygen, vasopressors).
- AVN RISK FACTORS: Femoral neck fracture (especially displaced), scaphoid fracture, talus fracture; delayed onset (months to years).
- AVN CONSEQUENCES: Joint collapse, arthritis, need for total joint replacement.
- CRUSH SYNDROME MANAGEMENT: Aggressively hydrate; monitor urine color (dark indicates myoglobin); measure creatinine kinase and myoglobin; insert urinary catheter for output monitoring; prepare for dialysis if renal failure develops.
Key Definitions
Term
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
Example
Patient with femur fracture on bed rest develops leg swelling and chest pain (PE signs).
Definition
Blood clots forming in immobilized limbs; PE occurs when clot travels to lungs; immobility is major risk factor.
Term
Osteomyelitis
Example
Compound tibia fracture with bone protruding through contaminated wound develops fever and localized bone pain.
Definition
Bone infection; especially after open fractures due to contamination; requires prolonged antibiotics.
Term
Hemorrhage and Hypovolemic Shock
Example
Pelvic fracture with internal hemorrhage causing hypotension, tachycardia, and altered mental status.
Definition
Fractures of large bones (femur, pelvis) can cause substantial internal bleeding; risk of shock and death.
Term
Avascular Necrosis (AVN)
Example
Femoral neck fracture with disrupted blood supply leading to AVN requiring later surgical intervention.
Definition
Death of bone tissue from loss of blood supply; commonly affects femoral head and scaphoid; delayed complication.
Term
Crush Syndrome
Example
Limb pinned under rubble for hours; dark urine and acute kidney injury develop.
Definition
Severe tissue injury from prolonged compression causing rhabdomyolysis, myoglobinuria, and acute renal failure.
Diagrams To Know
- Fracture complications flowchart: immobilization → risk factors → complications (DVT/PE, osteomyelitis, hemorrhage, AVN).
- Timeline of complications: early (hemorrhage, shock), intermediate (DVT/PE, infection), late (AVN, nonunion).
Common Values
Value
First 24–48 hours
Symbol
24–48 hrs
Quantity
Duration of ice application for soft tissue injury
Section Title
SOFT TISSUE INJURIES AND DISLOCATIONS
Important Facts
- RICE PROTOCOL FOR SPRAINS AND STRAINS: Rest (stop activity), Ice (first 24–48 hours to reduce swelling), Compression (elastic wrap), Elevation (above heart level).
- AFTER 24–48 HOURS: Heat can be applied to promote circulation and healing.
- DISLOCATION MANAGEMENT: (1) Assess neurovascular status immediately. (2) Immobilize joint as found—DO NOT attempt to force it back. (3) Apply ice to reduce swelling. (4) Notify provider for reduction (usually requires anesthesia or sedation). (5) Post-reduction: assess neurovascular status again, immobilize, ice, elevate, monitor for complications.
- DISLOCATION COMPLICATIONS: Neurovascular compromise, fractures at joint margin, soft tissue (ligament, tendon, nerve) damage.
- SUBLUXATION: If it reduces spontaneously and patient is stable, immobilize and monitor; if recurrent, may require surgical stabilization.
- PATIENT EDUCATION: For sprains/strains: RICE protocol, gradual return to activity, physical therapy; for dislocations: importance of immobilization post-reduction, physical therapy to regain strength and stability.
Key Definitions
Term
Sprain
Example
Ankle sprain from inversion injury; ligaments stretched or partially torn.
Definition
Stretch or tear of LIGAMENT (bone to bone); causes pain, swelling, limited movement; classified by severity (Grade I–III).
Term
Strain
Example
Hamstring strain from overstretching during sports.
Definition
Stretch or tear of MUSCLE or TENDON; causes pain, swelling, muscle spasm; classified by severity.
Term
Dislocation
Example
Anterior shoulder dislocation; humeral head displaced anteriorly.
Definition
Complete displacement of bone from joint; HIGH RISK of neurovascular compromise; orthopedic URGENCY.
Term
Subluxation
Example
Patella (kneecap) subluxation; may slide out of groove and back in.
Definition
Partial dislocation; bone incompletely displaced from joint; may reduce spontaneously.
Diagrams To Know
- RICE protocol timeline: first 24–48 hours (ice, compression, elevation) vs after 24–48 hours (heat, gentle mobilization).
- Common dislocations: shoulder (anterior), elbow (posterior), hip (posterior), patella (lateral).
Common Values
Value
First 24 hours only
Symbol
First 24 hrs
Quantity
Duration of stump elevation
Value
50–80% of amputees
Symbol
50–80%
Quantity
Incidence of phantom limb pain
Value
3–6 weeks post-op
Symbol
3–6 weeks
Quantity
Typical timing of prosthesis fitting
Section Title
AMPUTATION AND PHANTOM LIMB PAIN
Important Facts
- COMMON INDICATIONS FOR AMPUTATION: Peripheral vascular disease (most common in developed countries), diabetes (most common reason worldwide), severe trauma, infection/osteomyelitis, malignancy.
- PHANTOM LIMB PAIN IS REAL: Do NOT dismiss patient's report; acknowledge and validate; rooted in neurophysiology (peripheral and central sensitization, reorganization of motor cortex).
- POSTOPERATIVE HEMORRHAGE PRECAUTIONS: Keep tourniquet at bedside for emergency use if stump bleeds heavily; monitor dressing for drainage and signs of bleeding; report excessive bleeding immediately.
- STUMP ELEVATION: Elevate residual limb on pillow for FIRST 24 HOURS ONLY to reduce edema; then avoid prolonged elevation as it promotes hip flexion contracture (which interferes with prosthesis fitting and walking).
- CONTRACTURE PREVENTION: (1) Avoid placing pillows under knee (hip flexion) or between thighs for prolonged periods. (2) Encourage patient to lie PRONE periodically to prevent hip flexion contracture—critical for prosthesis training. (3) Ensure proper stump positioning. (4) Early passive and active range-of-motion exercises.
- STUMP CARE: Residual limb wrapping (elastic wrap or stump shrinker) to shape and condition for prosthesis; wrapping reduces edema and prepares limb for prosthetic socket fit; teach patient proper wrapping technique (figure-8 pattern, firm but not tourniquet-tight).
- PHANTOM LIMB PAIN MANAGEMENT: (1) Analgesics (opioids if severe). (2) Adjunctive medications: gabapentin, pregabalin (neuropathic pain agents), tricyclic antidepressants (amitriptyline). (3) Non-pharmacologic: mirror therapy (visual illusion moving amputated limb), TENS unit, relaxation techniques, distraction, visualization. (4) Physical therapy and prosthesis fitting may reduce pain.
- PSYCHOSOCIAL CARE: Grief over loss of limb and altered body image is normal; encourage expression of feelings; involve patient in care decisions; provide realistic expectations about rehabilitation and prosthesis use; connect with support groups and rehabilitation specialists; assess for depression and provide mental health support.
- PROSTHESIS FITTING: Typically begins 3–6 weeks post-op once stump is healed and edema reduced; requires assessment of strength, balance, motivation, and cognitive function.
- MOBILITY AND REHABILITATION: Encourage early mobility with assistance; teach crutch walking or walker use pre-prosthesis; prosthesis training is physically demanding; celebrate small achievements; involve rehabilitation team (PT/OT).
Key Definitions
Term
Amputation
Example
Below-knee amputation (BKA) for gangrene from diabetes; above-knee amputation (AKA) from malignancy.
Definition
Surgical removal of limb or part of limb; indications include PVD, diabetes, severe trauma, infection, malignancy.
Term
Phantom Limb Sensation
Example
Patient reports feeling pressure or tingling in amputated foot.
Definition
Perception that amputated limb is still present; tingling, itching, or pressure felt in absent limb; NORMAL physiologic phenomenon.
Term
Phantom Limb Pain (PLP)
Example
Patient reports severe cramping or shooting pain in amputated leg.
Definition
Actual pain perceived in amputated limb; REAL, not imaginary; occurs in 50–80% of amputees; most common in early post-op period.
Diagrams To Know
- Postoperative amputation care timeline: immediate (hemorrhage control) → first 24 hours (elevation for edema) → days 2+ (prone positioning, contracture prevention) → weeks (stump care, wrapping, early ambulation) → prosthesis fitting.
- Phantom limb pain management strategy: assessment → pharmacologic (analgesics, adjunctive meds) → non-pharmacologic (mirror therapy, TENS, relaxation).
Must Remember
- OPEN FRACTURE = Immediate risk of osteomyelitis and sepsis; cover with sterile dressing, control bleeding, administer antibiotics within 3 hours, give tetanus prophylaxis, assess neurovascular status.
- BONE HEALING SEQUENCE: Hematoma (1–3 days) → Soft Callus (≈1 week) → Hard Callus (weeks 2–6) → Ossification → Remodeling (months). Factors delaying healing: poor blood supply, infection, age, poor nutrition, smoking, diabetes, corticosteroids.
- FAT EMBOLISM SYNDROME: Occurs 24–72 hours after long-bone or pelvic fracture; classic triad = hypoxemia (dyspnea) + neurologic changes (confusion) + petechial rash (chest, axillae). PRIORITY: oxygen, elevate HOB, notify provider immediately. Prevention: early immobilization.
- COMPARTMENT SYNDROME = SURGICAL EMERGENCY with 4–6 hour window to prevent permanent damage. EARLIEST SIGN: severe pain worse on PASSIVE STRETCH of digits (most reliable indicator). DO NOT elevate above heart and DO NOT ice (both reduce arterial flow). Keep at heart level, loosen/bivalve cast, notify provider emergently, prepare for FASCIOTOMY.
- CAST CARE: Support wet plaster with palms (not fingers), elevate above heart for first 24–48 hours, apply ice, frequent neurovascular checks. DRY CAST: monitor for pain/numbness/coolness/odor/drainage; nothing inserted; assess pressure areas.
- TRACTION PRINCIPLES: Weights hang freely (never touch floor); ropes stay on pulleys; maintain countertraction; NEVER remove weights without order (disrupts alignment); skeletal traction requires aseptic pin-site care.
- PHANTOM LIMB PAIN IS REAL—NOT IMAGINARY. Acknowledge and validate patient's pain; do NOT dismiss. Management: analgesics + adjunctive meds (gabapentin, pregabalin, amitriptyline) + non-pharmacologic (mirror therapy, TENS, relaxation techniques). Most common early post-op.
- AMPUTATION POSTOPERATIVE: Keep tourniquet at bedside for hemorrhage control. Elevate stump on pillow for FIRST 24 HOURS ONLY to reduce edema; then avoid prolonged elevation. Encourage PRONE positioning periodically to prevent hip flexion contracture (critical for prosthesis fitting).
- SOFT TISSUE INJURY (SPRAIN/STRAIN): RICE protocol first 24–48 hours (Rest, Ice, Compression, Elevation); heat after 24–48 hours. Sprain = ligament tear (bone-to-bone); strain = muscle/tendon tear. Both managed similarly initially.
- DISLOCATION/SUBLUXATION: Assess neurovascular status immediately. DO NOT forcefully reduce. Immobilize as found; notify provider. Dislocation is HIGH-RISK for neurovascular compromise and soft-tissue damage. Subluxation may self-reduce but still requires evaluation.
Last Minute Tips
- OPEN FRACTURES = NLE LOVES THIS: Know antibiotic timing (within 3 hours), types of coverage needed, and that pulsatile lavage (copious irrigation) is standard to remove contamination. Remember: open = infection risk = emergency care priority.
- COMPARTMENT SYNDROME DECISION POINT: When you see 'severe pain worse on passive stretch' + recent fracture/cast, your action is IMMEDIATE—notify provider, loosen/remove cast, keep limb at heart level (NOT elevated), prepare for fasciotomy. This is the classic 'minute matters' emergency tested on NLE.
- FAT EMBOLISM TIMING TRAP: NLE will test 'When does FES typically appear?' Answer: 24–72 hours (not immediately, not weeks later). Also: petechial rash location matters—chest/axillae/conjunctiva (NOT just dependent areas like pressure areas).
- PHANTOM LIMB PAIN TRICK: NLE tests whether students know this is REAL and how to manage it. If you see 'patient reports pain in amputated limb,' the answer is NOT 'assess psychological status'—it's 'treat the pain with analgesics and non-pharmacologic methods.' Validate the patient; do NOT dismiss.
- STUMP ELEVATION REVERSAL: Common trap—students think 'elevate for comfort' applies to amputees long-term. Remember: elevation ONLY for first 24 hours to reduce edema; after that, position PRONE periodically to prevent hip flexion contractures (needed for prosthesis fitting and walking).
Comparison Tables
Rows
Values
- Skin intact
- Low
- Reduction and immobilization
- Standard approach
Property
Closed (Simple)
Values
- Breaks through skin
- HIGH (osteomyelitis, sepsis)
- Sterile dressing, antibiotics within 3 hrs, tetanus, reduction, surgery likely
- HIGH-YIELD: infection risk, antibiotic timing
Property
Open (Compound)
Values
- Multiple fragments
- High (from trauma severity)
- Stabilization, watch for nonunion/malunion
- Healing complications
Property
Comminuted
Values
- Incomplete, one side cracked
- Low
- Immobilization (usually conservative)
- Common in children
Property
Greenstick
Values
- Bone weakened by disease
- Varies (depends on cause)
- Treat underlying disease; may be fragile
- Osteoporosis, tumor, infection context
Property
Pathologic
Values
- Fragments out of alignment
- Moderate (depends on type)
- MUST reduce before healing
- Alignment importance
Property
Displaced
Values
- Fragments remain aligned
- Low
- Conservative (cast, traction)
- Usually straightforward
Property
Nondisplaced
Columns
- Fracture Type
- Characteristic
- Infection Risk
- Management Priority
- NLE Test Focus
Table Title
Fracture Types: Key Distinctions
Rows
Values
- Ligament (bone to bone)
- Muscle or tendon
- Different structures require different rehabilitation
Property
Tissue injured
Values
- Forceful joint twist or hyperextension
- Overstretching or forceful contraction
- History guides assessment
Property
Mechanism
Values
- Sudden (traumatic)
- Can be sudden or gradual (overuse)
- Chronic strains develop differently
Property
Onset
Values
- Sharp, localized to ligament
- Aching, localized to muscle/tendon
- Patient description helps differentiate
Property
Pain character
Values
- RICE (Rest, Ice, Compression, Elevation)
- RICE for first 24–48 hours
- Both use same initial protocol
Property
Initial treatment
Values
- After 24–48 hours
- After 24–48 hours
- Both progress from cold to heat
Property
Heat application
Values
- Joint instability (especially Grade III complete tear)
- Muscle weakness
- Sprains may need surgical repair; strains need strengthening
Property
Stability concern
Columns
- Feature
- Sprain
- Strain
- Nursing Implication
Table Title
Sprain vs Strain: Clinical Distinction
Rows
Values
- Complete (bone fully out of joint)
- Partial (bone incompletely displaced)
- Assess on X-ray; severity guides management
Property
Displacement
Values
- Rare; requires intervention
- May reduce spontaneously
- Clarify with provider for next steps
Property
Spontaneous reduction
Values
- HIGH; structures stretched and compressed
- Moderate; may have resolved if self-reduced
- Assess immediately before and after any intervention
Property
Neurovascular risk
Values
- Immobilize as found; DO NOT attempt forceful reduction
- Immobilize if still displaced; monitor if self-reduced
- Avoid further trauma; arrange provider evaluation
Property
Immobilization approach
Values
- Usually requires anesthesia/sedation (closed or open)
- May reduce spontaneously; closed reduction if needed
- Provider determines method
Property
Reduction method
Values
- Immobilization, neurovascular monitoring, PT for stability
- If recurring, may need surgical stabilization
- Early rehabilitation; prevent recurrence
Property
Post-reduction focus
Columns
- Feature
- Dislocation
- Subluxation
- Nursing Action
Table Title
Dislocation vs Subluxation: Urgent Management
Rows
Values
- Severe, unrelenting, out of proportion to injury
- EARLIEST sign; worse on passive stretch of digits
- Alerts to compartment syndrome immediately
- Act urgently on this sign; do NOT wait for other Ps
Property
Pain (P1)
Values
- Pale, white appearance of limb or digits
- Early to intermediate
- Indicates compromised perfusion
- Monitor skin color; blanching with pressure
Property
Pallor (P2)
Values
- Absent peripheral pulses
- LATE sign; indicates severe ischemia
- Do NOT wait for this to act; muscles may already be dying
- Earlier signs are more reliable; act before pulselessness develops
Property
Pulselessness (P3)
Values
- Tingling, numbness, pins-and-needles sensation
- Early to intermediate
- Nerve ischemia; reversible if caught early
- Assess sensation and report changes; nerve damage is preventable with early action
Property
Paresthesia (P4)
Values
- Weakness or inability to move limb or digits
- LATE sign; indicates muscle/nerve necrosis
- Irreversible if ischemia prolonged; indicates tissue death
- Avoid—act on earlier signs; paralysis means permanent damage
Property
Paralysis (P5)
Values
- Coolness of limb; temperature matches environment
- LATE sign; indicates severe ischemia
- Tissue death; irreversible
- Act on earlier signs; coolness indicates advanced ischemia
Property
Poikilothermia (P6)
Columns
- Sign
- Description
- Timing (Early vs Late)
- Clinical Significance
- Nursing Implication
Table Title
The 6 Ps of Compartment Syndrome: Timing and Significance
Rows
Values
- Rigid immobilization (plaster or fiberglass)
- Pulling force to maintain alignment and reduce muscle spasm
- Different approaches for different fractures and stages
Property
Mechanism
Values
- External; encases limb circumferentially
- Skeletal (pins in bone) or skin (adhesive); allows some movement
- Cast more restrictive; traction allows more freedom
Property
Type of immobilization
Values
- After reduction; during healing phase
- Initial management; may precede or complement cast
- Timing depends on fracture type and treatment plan
Property
When typically applied
Values
- Weeks to months (depends on bone and healing)
- Days to weeks (transitional); then cast applied
- Traction often precedes cast application
Property
Duration
Values
- Limited; must protect cast; partial or no weight-bearing
- More mobility; skeletal traction allows bed mobility
- Traction less restrictive initially; allows positioning
Property
Patient mobility
Values
- Pressure areas, skin breakdown, nerve compression, compartment syndrome if too tight
- Pin site infection (skeletal), skin irritation (skin), immobility complications
- Different complication profiles; both require frequent assessment
Property
Complication risk
Values
- Neurovascular checks, skin integrity, ensure cast stays dry, no objects inserted
- Pin site care (skeletal), weight management, rope/pulley maintenance, countertraction
- Different care protocols; both critical for patient safety
Property
Nursing care focus
Columns
- Feature
- Cast
- Traction
- Clinical Context
Table Title
Cast vs Traction: When to Use Each
Rows
Values
- FALSE
- Phantom pain is REAL; rooted in neurophysiology (cortical reorganization, peripheral/central sensitization)
- Acknowledge and validate patient's experience; never dismiss or minimize
- Treat as legitimate pain; provide appropriate pain management
Property
Phantom pain is imaginary
Values
- FALSE
- Most common early post-op but can persist for years in some patients
- Set realistic expectations; monitor for chronic pain; refer to pain management
- Ongoing assessment and management may be needed; support long-term
Property
Phantom pain always goes away quickly
Values
- Incomplete
- Phantom pain often requires multimodal approach (pharmacologic and non-pharmacologic)
- Combine analgesics, adjunctive meds, mirror therapy, TENS, relaxation
- Use evidence-based combination approaches; opioids alone often insufficient
Property
Phantom pain should be managed like regular pain only
Values
- FALSE
- Phantom pain is a normal neurophysiologic response to amputation; not psychiatric
- Do NOT attribute to psychological causes; treat as legitimate pain syndrome
- Screen for depression (common secondary to pain/loss), but primary issue is physical
Property
Patients with phantom pain have psychiatric problems
Columns
- Misconception
- Reality
- Nursing Response
- Evidence-Based Action
Table Title
Phantom Limb Pain: Myth vs Reality for Nurses
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Musculoskeletal Assessment and Diagnostics
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Degenerative, Inflammatory and Metabolic Bone Disorders
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