NLE Musculoskeletal Nursing — Fractures, Trauma and Orthopedic InjuriesCheat Sheet

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

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

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

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).

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

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

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

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

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

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

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

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

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

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

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

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

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

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).