NLE Musculoskeletal Nursing — Fractures, Trauma and Orthopedic InjuriesRevision Notes

Exam Tips

• NLE FAVORITE: Open fracture = compound = SKIN IS BROKEN = HIGH infection risk. This is the most commonly tested fracture type distinction.
• Remember the mnemonic for signs: PDFLSE — Pain, Deformity, Function loss, Loss of normal contour, Swelling, Ecchymosis.
• Greenstick = children; Comminuted = severe trauma with multiple fragments; Pathologic = disease-weakened bone.
• Spiral fracture + unusual history = consider abuse — especially in pediatric patients.
• For open fractures: First action is to COVER the wound with a sterile dressing and control bleeding — do NOT try to push the bone back.

Key Points

• A fracture is a break in the continuity of bone — it can result from trauma, pathologic processes (e.g., osteoporosis, tumor), or repetitive stress.
• CLOSED (Simple) fracture: skin is INTACT — lower infection risk. OPEN (Compound) fracture: bone breaks through the skin — HIGH risk of infection and osteomyelitis.
• COMPLETE fracture: bone broken all the way through. INCOMPLETE fracture: only partially broken (e.g., greenstick).
• COMMINUTED fracture: bone is splintered into multiple fragments — common in severe trauma.
• GREENSTICK fracture: bone bends and cracks on one side only — common in children because their bones are more pliable.
• SPIRAL fracture: twisting force creates a spiral fracture line — may raise suspicion of abuse (non-accidental trauma) especially in children.
• TRANSVERSE fracture: fracture line is straight across the bone — usually caused by direct blow.
• OBLIQUE fracture: fracture line is at an angle.
• IMPACTED fracture: one fragment is driven into another.
• DISPLACED fracture: fragments are out of alignment. NONDISPLACED: fragments remain aligned.
• PATHOLOGIC fracture: occurs in bone already weakened by disease (osteoporosis, bone tumor, infection).
• Clinical manifestations: Pain, Loss of function, Deformity, Shortening of the limb, Crepitus (grating sensation/sound), Swelling, Ecchymosis (bruising).

Definitions

Section Title

Types of Fractures

Common Mistakes

• Confusing open and closed fractures with displaced and nondisplaced — these are separate classification systems describing different features.
• Forgetting that greenstick fractures occur in children — do not apply this to adult bone descriptions.
• Assuming that crepitus should be assessed manually by moving the extremity — this causes pain and further damage.
• Mixing up sprain (ligament) and strain (muscle/tendon) — these are soft tissue injuries, NOT fractures.
• Forgetting that pathologic fractures can occur with minimal or no trauma — watch for this in patients with osteoporosis or malignancy.

Exam Tips

• NLE MNEMONIC for healing stages: 'Habang Sumasama ang Buto, Ok na Remodel' = Hematoma, Soft callus, Bony callus (hard), Ossification, Remodeling.
• Teach patients with fractures: adequate protein (tissue repair), calcium (bone mineralization), vitamin D (calcium absorption), and STOP SMOKING.
• Corticosteroids delay bone healing — important for patients with autoimmune conditions who fracture.
• Nonunion may require bone grafting — a surgical procedure to stimulate healing.
• Malunion can lead to long-term disability and may require osteotomy (surgical correction).

Key Points

• Bone healing is a sequential, overlapping process with 5 stages: Hematoma Formation → Soft Callus (Fibrocartilage) Formation → Hard Callus (Bony) Formation → Ossification → Remodeling.
• STAGE 1 — Hematoma Formation (Days 1–3): Bleeding from fractured bone ends forms a blood clot (hematoma) at the fracture site. This hematoma is the initial scaffold for healing.
• STAGE 2 — Fibrocartilage (Soft Callus) Formation (Around 1 week): Fibroblasts and chondroblasts invade the hematoma and form a fibrocartilaginous bridge across the fracture site.
• STAGE 3 — Bony (Hard) Callus Formation (Weeks 2–6): Osteoblasts replace the soft callus with woven bone (hard callus). The fracture site becomes firm.
• STAGE 4 — Ossification: The hard callus matures into solid, lamellar bone. The fracture is now clinically united.
• STAGE 5 — Remodeling (Months): Osteoblasts and osteoclasts reshape the bone along lines of mechanical stress, restoring its original contour and strength over months.
• Factors that DELAY healing: Poor blood supply, infection (osteomyelitis), advanced age, poor nutrition (low protein, calcium, vitamin D), smoking, diabetes, corticosteroid use.
• Complications of impaired healing: Delayed union (slower than expected), Nonunion (failure to heal — requires surgical intervention), Malunion (heals in a deformed/abnormal position).

Definitions

Section Title

Stages of Bone Healing

Common Mistakes

• Confusing the order of healing stages — remember Hematoma → Soft Callus → Hard Callus → Ossification → Remodeling (HSHOM).
• Forgetting that smoking impairs bone healing by causing vasoconstriction and reducing oxygenation to the fracture site.
• Neglecting nutritional factors — protein, calcium, and vitamin D are all essential for bone repair.
• Confusing osteoblasts (build bone) with osteoclasts (break down bone) — mix-up leads to wrong answers.
• Thinking remodeling is quick — it takes months to years, not days.

Exam Tips

• NLE PRIORITY: In a trauma patient with a fracture — ABC first, THEN address the fracture.
• Immobilize as found = legal and safety principle aligned with Philippine nursing practice under RA 9173 (scope of practice).
• For open fracture: Sterile dressing + bleeding control = PRIORITY before transport.
• ORIF is the treatment of choice for comminuted, displaced, and joint-involved fractures.
• External fixation = pins going through skin into bone = requires aseptic pin-site care to prevent osteomyelitis.

Key Points

• At the scene: PRIMARY SURVEY first — Airway, Breathing, Circulation (ABCs) before addressing the fracture.
• IMMOBILIZE THE FRACTURE IN THE POSITION FOUND — do NOT attempt to straighten or reduce the fracture in the field.
• Splint the joint ABOVE AND BELOW the fracture site before moving the patient.
• For open fractures: Cover wound with a sterile dressing to prevent contamination; control bleeding with direct pressure.
• NEUROVASCULAR ASSESSMENT: Assess circulation (color, warmth, capillary refill), sensation, and movement BEFORE AND AFTER splinting.
• CLOSED REDUCTION: Manual realignment of bone fragments under anesthesia — then immobilized with a cast or splint.
• OPEN REDUCTION AND INTERNAL FIXATION (ORIF): Surgery to align the fracture using plates, screws, or rods — used for displaced, comminuted, or complex fractures.
• EXTERNAL FIXATION: An external frame with pins inserted into the bone — used for open fractures, unstable fractures, or when the patient cannot tolerate anesthesia.

Definitions

Section Title

Emergency and Initial Fracture Management

Common Mistakes

• Attempting to straighten or reduce a fracture at the scene — always immobilize in position found.
• Forgetting to splint above AND below the fracture — only splinting one side is inadequate.
• Failing to assess neurovascular status before and after casting or splinting.
• Trying to reinsert protruding bone from an open fracture — cover with sterile dressing only.
• Delaying ABCs to assess the fracture — in a trauma patient, airway and circulation always come FIRST.

Exam Tips

• Remember: Wet cast = PALMS, not fingertips; ELEVATE first 24–48 hours; ICE first 24–48 hours; then HEAT after 48 hours.
• Traction: Weights must HANG FREELY = most commonly tested traction rule in NLE.
• Report to the doctor if: pain increases, fingers/toes become numb or cold, cast becomes wet or has foul odor — these indicate complications.
• Pin-site care = ASEPTIC technique = prevent osteomyelitis — especially for skeletal traction and external fixation.
• Cast smell: Foul odor from cast = possible infection under the cast — report immediately.

Key Points

• CASTS immobilize a reduced fracture and maintain alignment during healing. Types include plaster of Paris and fiberglass.
• Wet plaster cast: Support with PALMS (not fingertips) to prevent pressure points; handle gently until fully dry (24–72 hours for plaster).
• ELEVATE the casted limb above heart level for the FIRST 24–48 hours to reduce swelling.
• Apply ICE (indirect — with cloth barrier) for the first 24–48 hours to reduce swelling.
• Perform frequent NEUROVASCULAR CHECKS: Color, Warmth, Capillary refill, Sensation, Movement — distal to the cast.
• Patient teaching for casts: NEVER insert objects into the cast, report increasing pain/numbness/tingling/coolness/foul odor/drainage immediately.
• TRACTION maintains fracture reduction and reduces muscle spasm through application of a pulling force.
• CRITICAL traction rules: Weights must HANG FREELY and NEVER touch the floor or bed; ropes must stay on pulleys; maintain countertraction.
• For SKELETAL TRACTION: Perform aseptic pin-site care; assess for signs of infection (redness, drainage, crusting).
• NEVER remove or add traction weights without a physician's specific order — this disrupts fracture alignment.
• Complications of prolonged immobilization in cast/traction: DVT, pulmonary embolism, pressure ulcers, muscle atrophy, constipation.

Definitions

Section Title

Cast Care and Traction in Fracture Management

Common Mistakes

• Using fingertips instead of palms to support a wet plaster cast — causes indentations that create pressure points inside the cast.
• Elevating the traction weights off the floor — weights must hang freely; lifting them disrupts traction.
• Elevating the limb in traction beyond what maintains countertraction — follow specific traction protocol.
• Allowing patients to insert objects (rulers, chopsticks) inside casts to scratch — causes skin breakdown and infection.
• Forgetting that plaster casts take much longer to dry than fiberglass casts — patient must be careful for 24–72 hours.

Exam Tips

• MEMORIZE: FES = Long bone/Pelvis fracture + 24–72 hours later + Hypoxemia + Neurologic changes + Petechiae on chest/axillae/conjunctiva.
• Priority action = OXYGEN — always the first intervention for FES.
• NLE scenario clue: Patient fractured the femur in a vehicular accident → becomes confused and dyspneic on Day 2 → check for petechiae → FES.
• Prevention = gentle handling and early immobilization of fractures = prevents fat globule release.
• FES vs. PE (Pulmonary Embolism): FES has the classic TRIAD including petechiae and neurologic changes; PE usually has pleuritic chest pain and no petechiae.

Key Points

• Fat Embolism Syndrome (FES) occurs when fat globules from the bone marrow of a fractured LONG BONE or PELVIS enter the bloodstream.
• Fat globules travel to the lungs (causing respiratory failure), brain (causing neurologic changes), and skin (causing petechiae).
• TIMING: FES typically appears 24 to 72 HOURS after the injury — this is a critical NLE fact.
• CLASSIC TRIAD of FES: (1) HYPOXEMIA — dyspnea, tachypnea, decreased SpO2; (2) NEUROLOGIC CHANGES — confusion, restlessness, altered mental status, agitation; (3) PETECHIAL RASH — tiny pinpoint reddish-purple spots over the chest, axillae (armpits), and conjunctiva.
• Additional signs: Fever, tachycardia.
• PRIORITY NURSING INTERVENTION: Administer OXYGEN immediately to correct hypoxemia — this is the FIRST and most critical action.
• Position: Elevate head of bed (HOB) to improve respiratory effort.
• Notify the provider IMMEDIATELY — FES is life-threatening.
• PREVENTION: Early and gentle immobilization of long-bone fractures prevents fat globule release into the bloodstream.

Definitions

Section Title

Fat Embolism Syndrome (FES)

Common Mistakes

• Forgetting the 24–72 hour time frame — if a patient suddenly becomes confused or dyspneic 1–2 days after a femur fracture, think FES first.
• Missing the petechial rash because the nurse does not check the axillae and conjunctiva — always assess these areas in at-risk patients.
• Confusing neurologic changes with post-operative delirium — always rule out FES in a post-fracture patient with altered mental status.
• Delaying oxygen administration while waiting for the doctor's order — oxygen for hypoxemia is a standing nursing priority.
• Not knowing which bones are at risk — LONG BONES (femur, tibia) and the PELVIS are the highest-risk fracture sites for FES.

Exam Tips

• CRITICAL NLE RULE: Compartment syndrome = do NOT elevate; do NOT apply ice; KEEP AT HEART LEVEL; NOTIFY DOCTOR; BIVALVE CAST; PREPARE FOR FASCIOTOMY.
• MNEMONIC for 6 Ps: 'Painful Pale Pulseless Paraesthetic Paralysed and Poikilothermic' — Pain is FIRST and EARLIEST; Pulselessness and Paralysis are LATE.
• NLE scenario: Patient post-tibial fracture has cast. Reports severe, unrelenting pain. Passive dorsiflexion of toes causes sharp increase in pain. FIRST ACTION = notify provider, then prepare to bivalve cast.
• Compartment syndrome is caused by the INELASTIC fascia — unlike skin, fascia cannot stretch, so rising pressure has nowhere to go.
• Time is tissue: 4–6 hours is the window before irreversible damage — act IMMEDIATELY.

Key Points

• Compartment syndrome is a TRUE SURGICAL EMERGENCY — irreversible muscle and nerve damage can occur within 4 to 6 HOURS if not treated.
• It occurs when pressure within a closed muscle compartment (bounded by INELASTIC FASCIA) rises to a level that compromises circulation and perfusion.
• CAUSES: Internal — bleeding and swelling inside the compartment after fracture; External — tight cast, tight dressing, or circumferential burn.
• THE 6 Ps of Compartment Syndrome: PAIN, PALLOR, PULSELESSNESS, PARESTHESIA, PARALYSIS, POIKILOTHERMIA.
• PAIN is the EARLIEST and MOST RELIABLE sign — it is SEVERE, UNRELENTING, out of proportion to the injury, and WORSENS with PASSIVE STRETCH of the digits (e.g., passively extending the fingers in forearm compartment syndrome).
• PULSELESSNESS and PARALYSIS are LATE signs — do NOT wait for these before acting.
• NURSING MANAGEMENT (EMERGENCY ACTIONS): (1) NOTIFY THE PROVIDER IMMEDIATELY; (2) Do NOT elevate the extremity above heart level — keep at HEART LEVEL; (3) Do NOT apply ice; (4) Loosen or BIVALVE the cast as ordered; (5) Remove tight dressings; (6) Prepare for FASCIOTOMY.
• FASCIOTOMY: Emergency surgical incision of the fascia to relieve compartment pressure — definitive treatment.
• After fasciotomy: wounds are left OPEN and packed, then closed by delayed primary closure or skin grafting.
• Normal compartment pressure: < 10 mmHg. Compartment syndrome is diagnosed when pressure exceeds 30 mmHg or is within 30 mmHg of diastolic blood pressure.

Definitions

Section Title

Compartment Syndrome — Surgical Emergency

Common Mistakes

• ELEVATING the affected extremity in compartment syndrome — this WORSENS ischemia by reducing arterial blood flow. Keep at HEART LEVEL.
• Applying ice to the extremity in compartment syndrome — ice causes vasoconstriction and further reduces perfusion.
• Waiting for pulselessness before acting — by the time pulses are absent, tissue death may have already occurred.
• Confusing compartment syndrome with normal post-fracture pain — the key is that compartment syndrome pain is OUT OF PROPORTION, unrelenting, and worsened by passive stretch.
• Forgetting to bivalve the cast — releasing external pressure from a tight cast is an immediate and important nursing intervention.

Exam Tips

• SPRAIN = Ligament (bone-to-BONE) | STRAIN = muScle/tendon (muscle-to-BONE) — remember 'S for Sprain, S for Separate bones.'
• RICE first 24–48 hours — then HEAT after 48 hours to promote blood flow and healing.
• Dislocation = URGENCY — immobilize as found, assess neurovascular status, report to provider for reduction.
• Do NOT reduce a dislocated joint at the scene — only trained providers should perform reduction under appropriate conditions.
• For compression in RICE: use an elastic bandage (ACE wrap) — apply firmly but not so tight as to cause neurovascular compromise.

Key Points

• SPRAIN: A stretch or TEAR of a LIGAMENT (connects bone to bone). Example: ankle sprain when the lateral ligaments are stretched.
• STRAIN: A stretch or TEAR of a MUSCLE or TENDON (connects muscle to bone). Example: hamstring strain in athletes.
• Both cause pain, swelling, tenderness, and limited movement — distinguish by the type of tissue involved.
• FIRST-LINE MANAGEMENT for sprains and strains: RICE — Rest, Ice (first 24–48 hours), Compression (elastic bandage), Elevation above heart level.
• After 48 hours: HEAT may be applied to promote circulation and facilitate healing.
• DISLOCATION: Complete displacement of a bone from its joint — a true orthopedic urgency.
• SUBLUXATION: Partial dislocation — the joint surfaces are partially separated.
• Dislocations can compress nerves and blood vessels — ASSESS NEUROVASCULAR STATUS IMMEDIATELY.
• Management: Immobilize the joint in position found; do NOT attempt to force the joint back; prepare for reduction by the provider.
• Common dislocation sites: Shoulder (most common), hip, knee, fingers, jaw (temporomandibular joint).

Definitions

Section Title

Soft Tissue Injuries and Dislocations

Common Mistakes

• Applying heat immediately to a fresh sprain or strain — ice is used FIRST (24–48 hours) to reduce swelling; heat comes AFTER 48 hours.
• Confusing sprain (ligament) and strain (muscle/tendon) — this is a classic NLE distractor.
• Attempting to relocate a dislocated joint by force — this can cause further injury to nerves, vessels, and cartilage.
• Forgetting to assess neurovascular status after a dislocation — displaced bone can compress vessels and nerves.
• Using RICE incorrectly — elevation must be ABOVE heart level, not just 'raised.'

Exam Tips

• NLE KEY: After amputation — TOURNIQUET at bedside (for hemorrhage); Elevate stump for 24 hours ONLY; then prone positioning to prevent hip contracture.
• Phantom limb pain = REAL = ACKNOWLEDGE IT — the wrong answer is always to dismiss or ignore the patient's pain report.
• Gabapentin and pregabalin = neuropathic pain drugs = first-line pharmacologic treatment for phantom limb pain.
• Body image disturbance (NANDA nursing diagnosis) is the priority psychosocial nursing diagnosis after amputation.
• For the NLE: 'What position prevents hip flexion contracture after above-knee amputation?' = PRONE position.

Key Points

• AMPUTATION is the surgical removal of a limb or part of a limb — most commonly done for peripheral vascular disease, diabetes (diabetic gangrene), severe trauma, malignancy, or uncontrolled infection.
• In the Philippine context, diabetes-related lower extremity amputation is highly prevalent — diabetic foot complications are a leading cause of amputation.
• POSTOPERATIVE CARE — HEMORRHAGE: Keep a TOURNIQUET at the bedside at all times for emergency use if the stump bleeds profusely. Monitor the dressing frequently.
• POSITIONING to prevent contractures: ELEVATE the residual limb on a pillow for FIRST 24 HOURS ONLY to reduce edema, then DISCONTINUE prolonged elevation.
• Place the patient in PRONE position periodically to PREVENT HIP FLEXION CONTRACTURES — especially for below-knee and above-knee amputees.
• Do NOT place pillows under the knee (for below-knee amputees) or between the thighs (for above-knee amputees) for prolonged periods — causes contractures.
• STUMP CARE: Wash with mild soap and water daily; inspect for skin breakdown; perform wrapping and shaping of the residual limb for prosthesis fitting.
• PHANTOM LIMB PAIN (PLP): The patient perceives pain, tingling, or sensation as if the amputated limb is still present — this is a REAL, physiologic phenomenon, not imaginary.
• NURSING RESPONSIBILITY: ACKNOWLEDGE and VALIDATE the patient's pain — NEVER dismiss it as 'psychological' or imaginary.
• Management of phantom limb pain: Analgesics, Gabapentin/Pregabalin (neuropathic pain agents), antidepressants, Mirror therapy, TENS (transcutaneous electrical nerve stimulation), relaxation techniques.
• PSYCHOSOCIAL CARE: Amputation involves grief, altered body image, and role changes — allow expression of feelings, include patient in care decisions, connect with rehabilitation and peer support groups.

Definitions

Section Title

Amputation and Phantom Limb Pain

Common Mistakes

• Elevating the residual limb for more than 24 hours — after 24 hours, prolonged elevation can cause contractures and is no longer needed for edema.
• Dismissing phantom limb pain as imaginary or 'in the patient's head' — this is both clinically incorrect and a violation of the nurse's duty to acknowledge patient pain.
• Forgetting to keep a tourniquet at the bedside — hemorrhage from the stump is a life-threatening emergency that requires immediate action.
• Placing a pillow under the knee (below-knee amputee) or between the thighs (above-knee amputee) for prolonged periods — causes knee or hip flexion contractures.
• Forgetting that diabetes is the MOST COMMON cause of amputation in the Philippine context — relevant for patient teaching on prevention.

Exam Tips

• Crutch walking: Weight on HANDS (handgrips), NOT armpits — prevents crutch palsy (brachial plexus compression).
• For bone healing: Protein + Calcium + Vitamin D = the nutritional triad. Teach Filipino patients: malunggay (calcium source), eggs, dairy, sardines.
• NLE discharge teaching question: The MOST IMPORTANT sign to report after casting = increasing pain, numbness, or loss of sensation (may indicate compartment syndrome).
• For fracture patients: Sunlight exposure is important for vitamin D synthesis — relevant in Philippine tropical climate.

Key Points

• Cast care at home: Keep cast dry; never insert objects into the cast; report any increasing pain, numbness, tingling, coolness, foul odor, or wet spots immediately.
• Safe use of assistive devices: Teach correct crutch walking technique — weight on hands/axillary pads (not armpits) to prevent brachial plexus injury ('crutch palsy').
• Weight-bearing precautions: Follow prescribed weight-bearing status (non-weight bearing, partial, toe-touch, full).
• Nutrition for bone healing: Increase protein (meat, eggs, legumes — sources available in Philippine diet), calcium (dairy, malunggay, sardines), and vitamin D (sunlight, fortified foods).
• Smoking cessation: Smoking impairs bone healing by reducing oxygen delivery — strongly advise cessation.
• Warning signs to report immediately: Signs of compartment syndrome (severe increasing pain, numbness, pallor), signs of DVT (calf pain, swelling, redness), signs of infection (fever, foul odor, redness at wound site).
• Rehabilitation: Emphasize the importance of physical therapy exercises, compliance with follow-up appointments, and gradual return to function.
• For amputees: Teach stump care, prosthesis care, fall prevention, and phantom limb pain management strategies.

Definitions

Section Title

Patient and Family Teaching for Fractures and Orthopedic Injuries

Common Mistakes

• Teaching patients that all cast odors are normal — FOUL odor suggests infection under the cast.
• Not teaching correct crutch technique — students forget that weight should be on the HANDS, not the axillary area.
• Forgetting dietary teaching — calcium, protein, and vitamin D are all essential for bone healing.
• Omitting smoking cessation counseling from discharge teaching — smoking significantly delays bone healing.