Fractures — breaks in the continuity of bone — are among the most common injuries nurses encounter across emergency departments, medical-surgical floors, orthopedic units, and long-term care settings. In the United States, approximately 6.3 million fractures occur annually. They range from minor stress fractures managed with rest and activity modification to life-threatening open long-bone fractures with massive hemorrhage requiring emergent surgery. Nurses must be proficient in fracture classification, neurovascular assessment, recognition of life-threatening complications, perioperative care, and patient education. This reference page provides the depth required for clinical practice and NCLEX preparation, with particular emphasis on the high-yield complications that appear most frequently on licensing examinations: compartment syndrome, fat embolism syndrome, and avascular necrosis.
Fast-scan summary
| Parameter | Key facts |
|---|---|
| Definition | Break in the structural continuity of bone caused by force exceeding bone tensile strength, pathologic weakening, or repetitive stress |
| Most common fracture sites | Distal radius (Colles'), hip (femoral neck/intertrochanteric), vertebral body, ankle, tibia/fibula, clavicle |
| Neurovascular assessment | The 6 Ps: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia — perform every 1–2 hours post-injury or post-op |
| Highest-priority complication | Compartment syndrome — pain with passive stretch is earliest sign; requires emergent fasciotomy |
| Fat embolism syndrome (FES) timing | 24–72 hours post long-bone or pelvic fracture; triad: hypoxemia, neurologic changes, petechial rash |
| Hip fracture AVN risk | Femoral neck (intracapsular) fracture disrupts blood supply → avascular necrosis in 15–30% of cases |
| Open fracture priority | IV antibiotics within 1–3 hours of injury; sterile wound coverage; irrigation and debridement in OR |
| Key surgical procedures | ORIF (open reduction internal fixation), intramedullary nailing, hemiarthroplasty/total hip arthroplasty |
| DVT/PE risk | Fracture + immobility = Virchow's triad activated; hip and pelvic fractures carry highest thromboembolic risk |
| Post-op hip precautions (posterior approach) | No hip flexion >90°, no internal rotation, no adduction past midline — prevent dislocation |
Fracture classification
Fractures are classified along several axes: pattern/morphology, displacement, completeness, and skin integrity. Understanding classification guides management decisions and nursing priorities.
Classification by fracture pattern
| Type | Description | Mechanism | Clinical notes |
|---|---|---|---|
| Transverse | Fracture line perpendicular (90°) to the long axis of the bone | Direct blow, bending force | Relatively stable; less shortening than oblique |
| Oblique | Fracture line at an angle to the long axis (<90°) | Angular force, axial loading with bending | Tends to shorten and displace |
| Spiral | Fracture winds around the bone shaft in a spiral configuration | Torsional/twisting force | In children, raises suspicion for non-accidental trauma |
| Comminuted | Three or more bone fragments | High-energy trauma (MVC, crush injury, gunshot) | Difficult to reduce and fixate; high soft tissue damage; elevated blood loss risk |
| Greenstick | Incomplete fracture — bone bends and breaks on one cortex, intact on the other | Bending force; occurs in children whose bones are more flexible | Pediatric fracture; angular deformity common; generally heals well |
| Stress (fatigue) | Incomplete fracture from repetitive loading below the threshold of a single acute fracture | Repetitive mechanical stress (running, marching) | X-ray often negative initially; MRI or bone scan for diagnosis; common in metatarsals, tibia, femoral neck |
| Pathologic | Fracture through abnormal (weakened) bone from minimal or no trauma | Osteoporosis, metastatic malignancy, Paget's disease, primary bone tumor | Vertebral compression fractures are the most common pathologic fracture; see osteoporosis nursing for risk factors |
| Avulsion | Bone fragment pulled away by tendon or ligament at its attachment point | Sudden forceful muscle contraction or ligamentous traction | Common at base of 5th metatarsal, tibial tubercle, medial epicondyle |
| Impacted | One bone fragment driven into the other; both cortices disrupted | Axial loading (e.g., fall on outstretched hand, fall from height) | Often stable; telescoping of fragments; seen in femoral neck fractures |
| Compression | Collapse of cancellous bone under axial load | Axial loading; osteoporosis; vertebral bodies most common site | Vertebral compression fractures cause height loss and kyphosis (dowager's hump) |
Classification by displacement and completeness
| Category | Classification | Description | Nursing implication |
|---|---|---|---|
| Displacement | Non-displaced | Fracture fragments remain in normal anatomical alignment | Cast or splint immobilization usually sufficient; monitor for delayed displacement |
| Displaced | Fragments have moved from their normal position | Requires reduction (closed or open); monitor neurovascular status closely | |
| Angulated | Fragments form an angle at the fracture site | Document direction and degree of angulation; may require manipulation | |
| Rotated | Distal fragment rotated relative to proximal | Compare limb rotation bilaterally; assess for malrotation post-reduction | |
| Completeness | Complete | Fracture line traverses the full diameter of the bone; both cortices disrupted | Higher instability; surgical fixation more likely required |
| Incomplete | Fracture line does not traverse the full diameter; one cortex intact | Greenstick and torus (buckle) fractures are incomplete; generally more stable |
Classification by skin integrity: closed vs open fractures
The distinction between closed (simple) and open (compound) fractures has immediate management implications. Open fractures communicate with the external environment through a wound, dramatically increasing infection risk — including osteomyelitis, tetanus, and gas gangrene.
The Gustilo-Anderson classification is the standard system for grading open fracture severity:
| Grade | Wound size | Contamination | Soft tissue damage | Infection risk | Nursing priorities |
|---|---|---|---|---|---|
| Type I | <1 cm | Minimal; clean wound | Minimal; inside-out puncture (bone pokes through skin) | ~2% | Cover with sterile saline-moistened dressing; IV antibiotics (cefazolin) within 1–3 hours |
| Type II | 1–10 cm | Moderate contamination | Moderate muscle damage, no extensive soft tissue loss | ~5–7% | Sterile dressing, IV antibiotics; prepare for urgent OR irrigation and debridement |
| Type IIIA | >10 cm | High contamination | Extensive soft tissue damage; adequate bone coverage possible | ~7% | Broad-spectrum antibiotics (add gentamicin ± metronidazole); neurovascular assessment; blood loss monitoring |
| Type IIIB | >10 cm | High contamination | Extensive periosteal stripping; inadequate bone coverage; requires flap | ~10–50% | Same as IIIA; anticipate multiple OR returns; wound VAC possible; high risk of osteomyelitis |
| Type IIIC | Any | High contamination | Vascular injury requiring repair; limb ischemia | >50% | Emergent vascular surgery consultation; monitor for ischemia; amputation possible if vascular repair fails |
Key nursing rule: Never remove dressings from open fractures in the ED to “take a look.” Expose once, cover with sterile dressing, and keep covered until the OR. Each exposure increases contamination.
High-yield fracture locations
Hip fractures
Hip fractures are among the most clinically significant fractures nurses encounter, particularly in older adults with osteoporosis. Approximately 300,000 hip fractures occur in the United States annually; 30-day mortality approaches 5–10%, and 1-year mortality reaches 20–30% in elderly patients.
Hip fractures are anatomically divided into two categories with different blood supply implications:
| Parameter | Intracapsular (femoral neck) | Extracapsular (intertrochanteric / subtrochanteric) |
|---|---|---|
| Location | Within the joint capsule, at the femoral neck | Outside the joint capsule, at the trochanters or proximal shaft |
| Blood supply to femoral head | Disrupted — medial/lateral circumflex femoral arteries travel along the neck; fracture interrupts them | Usually preserved — blood supply enters below the fracture |
| AVN risk | High — 15–30% in displaced fractures; ischemia leads to femoral head collapse | Low — blood supply intact |
| Preferred surgical treatment | Hemiarthroplasty or total hip arthroplasty (displaced); internal fixation (non-displaced, younger patients) | ORIF with sliding hip screw or intramedullary nail |
| Classic presentation | Shortened, externally rotated leg; groin pain; inability to bear weight | Shortened, externally rotated leg (more pronounced); thigh and groin pain |
| Blood loss | Minimal — contained within capsule | Significant — extracapsular space accommodates large hematoma; 500–2,000 mL possible |
Garden classification grades femoral neck fractures by displacement, with Garden I (incomplete, valgus impacted) and Garden II (complete, non-displaced) carrying lower AVN risk, and Garden III (complete, partial displacement) and Garden IV (complete, full displacement) carrying the highest AVN risk.
Nursing assessment priorities for hip fracture:
- External rotation and limb shortening on the affected side
- Skin assessment (heels especially) — immobility + bony prominence = rapid pressure injury development
- Neurovascular assessment of the entire affected extremity
- Pain management — multimodal, opioid-sparing approach where possible
- DVT prophylaxis — chemical (LMWH, fondaparinux) + mechanical (compression devices) initiated promptly
- Urinary retention — common post-op; monitor output; catheterization if needed
Colles’ fracture
Colles’ fracture is a distal radius fracture with dorsal angulation and displacement of the distal fragment, producing the characteristic dinner fork deformity on lateral X-ray. It is the most common wrist fracture in adults and results from a FOOSH mechanism (Fall On OutStretched Hand), most commonly in postmenopausal women with osteoporosis.
Clinical features: dorsal displacement creating a visible deformity, radial deviation, wrist swelling and ecchymosis, point tenderness over the distal radius. Management ranges from closed reduction with casting (non-displaced or minimally displaced) to ORIF with volar locking plate (unstable or intra-articular fractures).
Nursing considerations: Elevate the extremity above heart level to reduce swelling; assess radial pulse and median nerve function (sensation in the thumb, index, and middle fingers); monitor cast fit — swelling post-reduction can cause cast tightness and early compartment syndrome.
Vertebral compression fractures
Vertebral compression fractures (VCFs) occur when the vertebral body collapses under compressive load. In the setting of osteoporosis, they can occur with minimal trauma — bending forward to pick up an object, a minor fall, or even a cough. The thoracolumbar junction (T12–L1) is most commonly affected.
Clinical features: acute onset of back pain, loss of height, progressive thoracic kyphosis (dowager’s hump), and restricted mobility. Neurologic deficit is uncommon in osteoporotic VCFs but must be assessed. Multiple VCFs produce cumulative height loss and can restrict pulmonary function due to thoracic cage compression.
Management options include conservative care (analgesics, bracing, activity modification) and minimally invasive procedures: vertebroplasty (injection of bone cement under fluoroscopy) and kyphoplasty (balloon inflation to restore height before cement injection).
Nursing considerations: Fall prevention is paramount; log-roll technique for repositioning; HOB positioning for comfort; assess respiratory function in multilevel VCFs; teach fall prevention and the importance of treating underlying osteoporosis.
Long bone fractures (femur shaft and tibia)
Femur shaft fractures are high-energy injuries requiring significant force in young adults (MVC, pedestrian injuries, falls from height). In elderly patients, lower-energy mechanisms suffice. Key concern: massive blood loss. The femoral shaft is surrounded by large muscle compartments and a thigh hematoma can accommodate 1–3 liters of blood — enough to cause hemorrhagic shock. Patients may present in hemodynamic compromise.
Tibial shaft fractures are among the most common long bone fractures and carry significant compartment syndrome risk due to the tight fascial compartments of the leg (anterior, lateral, superficial posterior, deep posterior). The tibia has limited soft tissue coverage anteriorly, making open fractures common.
Nursing priorities: IV access (large-bore, bilateral preferred); fluid resuscitation; continuous hemodynamic monitoring (see vital signs by age for age-adjusted targets); hourly neurovascular checks; traction splinting for femur fractures in the prehospital/ED setting.
Clavicle fractures
Clavicle fractures are among the most common fractures overall, accounting for approximately 5% of all fractures. The middle third is fractured in 80% of cases. Mechanism: direct blow to the shoulder or FOOSH. Management is typically non-operative with a sling or figure-of-8 brace.
Nursing neurovascular assessment focus: Brachial plexus (assess sensation and strength in the arm and hand), subclavian artery and vein (assess radial pulse, capillary refill, and venous congestion), and pneumothorax (auscultate bilateral breath sounds — displaced fragments can lacerate the apex of the lung or subclavian vessels).
Rib fractures
Rib fractures are painful and impair respiratory mechanics. The primary concern is splinting — shallow breathing to avoid pain — leading to atelectasis, retained secretions, and pneumonia.
Flail chest occurs when three or more consecutive ribs are fractured in two or more places, creating a free-floating segment that moves paradoxically (inward on inspiration, outward on expiration), impairing ventilation. Associated injuries include pulmonary contusion.
Complications of rib fractures: pneumothorax, hemothorax, pulmonary contusion, flail chest, splenic or hepatic laceration (lower rib fractures). Nursing interventions: incentive spirometry every 1–2 hours, adequate analgesia (regional nerve blocks are preferred over systemic opioids to avoid respiratory depression), positioning, and chest physiotherapy.
Clinical presentation and assessment
Signs and symptoms of fracture
The cardinal signs of fracture are recognizable and form the basis of initial assessment:
| Sign/symptom | Description | Clinical significance |
|---|---|---|
| Deformity | Abnormal angulation, shortening, or rotational malalignment of the limb | Visible in displaced fractures; confirm bilaterally by comparing limb length and rotation |
| Swelling and ecchymosis | Soft tissue edema and subcutaneous bleeding around the fracture site | May obscure deformity; swelling increases over first 24–48 hours; monitor for compartment syndrome |
| Point tenderness | Pain precisely localized to the fracture site on palpation | High sensitivity for fracture; helps differentiate fracture from sprain |
| Crepitus | Grating sensation or sound from fractured bone ends moving against each other | Do not intentionally elicit — causes pain and can worsen soft tissue damage; if felt during assessment, note and report |
| False motion | Abnormal movement at a site where there is no joint | Pathognomonic of complete fracture; do not reproduce — immobilize immediately |
| Loss of function | Inability or reluctance to use the affected extremity | Present in virtually all significant fractures; assess active and passive range of motion carefully |
| Pallor / skin changes | Pale, mottled, or tented skin over fracture fragment | May indicate impending skin perforation (closed to open) or vascular compromise |
The 6 Ps: neurovascular assessment
Neurovascular assessment is the cornerstone of fracture nursing care. Perform a complete 6-P assessment on the affected extremity distal to the fracture or cast:
| P | Assessment | Normal finding | Abnormal finding / action |
|---|---|---|---|
| Pain | Assess pain quality, location, and response to analgesics; specifically assess pain with passive stretch of muscles in the affected compartment | Pain controlled with analgesics; no pain with passive stretch | Pain disproportionate to injury, unrelieved by opioids, or provoked by passive stretch → compartment syndrome until proven otherwise; notify provider immediately |
| Pallor | Inspect skin color; compare with contralateral limb; assess capillary refill (<2 seconds is normal) | Pink, well-perfused; capillary refill <2 seconds | Pallor, cyanosis, or mottling → arterial compromise; capillary refill >3 seconds → report immediately |
| Pulselessness | Palpate and compare pulses distal to fracture (e.g., radial for forearm, dorsalis pedis and posterior tibial for leg) | Strong, equal bilateral pulses | Absent or diminished pulse → vascular injury or compartment syndrome; emergent surgical consultation |
| Paresthesia | Ask patient about numbness, tingling, or "pins and needles" in the distal extremity; test light touch with fingertip | Normal sensation throughout | Paresthesia is often the earliest neurologic finding of compartment syndrome; even subtle tingling warrants immediate escalation |
| Paralysis | Ask patient to move fingers/toes; assess grip strength and plantar/dorsiflexion | Full active movement | Weakness or inability to move → neural or vascular compromise; late finding in compartment syndrome |
| Poikilothermia | Palpate temperature of the distal extremity; compare bilaterally | Warm, equal bilaterally | Cool or cold extremity → arterial compromise; warmth may persist initially even with vascular injury |
Frequency: Perform neurovascular checks every 1–2 hours for the first 24 hours post-injury or post-operatively, then every 4 hours when stable. For fresh casts: every 30 minutes for the first 4 hours, then hourly. Any deterioration in any parameter warrants immediate notification and escalation.
Fat embolism syndrome
Fat embolism syndrome (FES) is a serious complication occurring 24–72 hours after long bone fractures (particularly femur and tibia) or pelvic fractures, and less commonly after orthopedic surgery, total joint arthroplasty, liposuction, or prolonged corticosteroid use.
Pathophysiology: Two theories exist. The mechanical theory proposes that fat globules from disrupted marrow enter ruptured intramedullary veins and embolize to the pulmonary vasculature. The biochemical theory proposes that circulating free fatty acids (released by enzymatic hydrolysis of fat emboli) cause direct endothelial injury and inflammatory cascade activation in the lungs and brain.
Gurd criteria for diagnosis:
| Category | Criterion | Notes |
|---|---|---|
| Major criteria | Respiratory insufficiency (PaO₂ <60 mmHg on room air, SpO₂ <90%) | Must have at least one major criterion for diagnosis |
| Cerebral involvement (confusion, restlessness, altered LOC not explained by head injury) | ||
| Petechial rash | Axillae, conjunctivae, anterior chest, neck — the pathognomonic finding of FES | |
| Minor criteria | Tachycardia (>120 bpm), pyrexia (>38.5°C), retinal emboli, fat macroglobulinemia | Requires major criterion + 4 minor criteria or 2 major criteria for diagnosis |
| Lipuria, thrombocytopenia (>50% drop from baseline), high ESR (>71 mm/hr) |
Nursing assessment: Monitor all long bone fracture patients for FES in the 24–72 hour window. Assess mental status changes, SpO₂ trends, and skin — the petechial rash (conjunctivae, axillae, upper chest) is the most specific finding. FES must be differentiated from pulmonary embolism; see pulmonary embolism nursing for the PE assessment. Key differential: PE typically presents suddenly; FES has a more gradual onset with the classic triad developing over hours.
Nursing interventions for FES: Supplemental oxygen (high-flow), positioning (semi-Fowler’s to optimize ventilation), prepare for possible intubation and mechanical ventilation, IV access, continuous SpO₂ monitoring, notify provider immediately. No specific pharmacologic treatment exists; management is supportive. Early surgical stabilization of long bone fractures has been shown to reduce FES incidence.
Diagnostics
Imaging
| Modality | When used | Advantages | Limitations | Nursing considerations |
|---|---|---|---|---|
| Plain X-ray | First-line for all suspected fractures; minimum 2 views (AP + lateral) of bone including joints above and below | Rapid, widely available, low cost, low radiation | May miss stress fractures, occult fractures, and soft tissue injury; 2D images can miss complex fracture patterns | Ensure proper positioning; immobilize limb before transport; remove jewelry; explain procedure to patient |
| CT scan | Complex fractures (intra-articular, pelvis, spine, calcaneus); pre-surgical planning; polytrauma | Superior detail for complex anatomy; 3D reconstruction; identifies associated injuries | Higher radiation; cost; time in scanner | Screen for contrast allergy and renal function if contrast used; IV access; monitor hemodynamics during transport |
| MRI | Stress fractures (negative X-ray but clinical suspicion), occult fractures, soft tissue injury (ligaments, meniscus), suspected AVN, cord/nerve compromise | No radiation; best soft tissue detail; detects bone marrow edema early (stress fractures positive 2–3 days after onset) | Time-intensive; expensive; contraindicated with some metallic implants and pacemakers; claustrophobia | MRI safety screening (implants, pacemaker, cochlear implants); remove all metal; monitor patient in scanner (no easy access) |
| Bone scan | Stress fractures when MRI unavailable, multifocal disease, suspected pathologic fractures, osteomyelitis | Highly sensitive; whole-body survey possible | Non-specific (any bone turnover lights up); not useful in first 24–72 hours post-acute fracture; radiation exposure | Explain radiotracer injection (Tc-99m); patient must be still for scan; delay of 2–4 hours between injection and imaging |
| Doppler ultrasound | Vascular injury, DVT assessment | Bedside-capable, no radiation, real-time vascular assessment | Operator-dependent; limited in obese patients or with extensive swelling | Position extremity as directed; note tourniquet time if vascular surgery involved |
Laboratory values
In the context of fractures, key labs include:
- CBC: Hemoglobin and hematocrit to quantify blood loss; thrombocytopenia may indicate DIC (especially in polytrauma or fat embolism); WBC elevated in infection
- Type and screen / crossmatch: Mandatory for hip fractures, femur fractures, pelvic fractures, and anticipated surgery
- BMP: Baseline electrolytes, BUN/creatinine (renal function — relevant for contrast use, NSAID prescribing, and rhabdomyolysis monitoring)
- Coagulation (PT/INR, aPTT): Pre-op; anticoagulation status (patients on warfarin); DIC screen in polytrauma
- Serum lactate: In hemodynamically compromised patients — assess perfusion and response to resuscitation
- CK (creatine kinase): If rhabdomyolysis is suspected (crush injury, prolonged compartment syndrome); markedly elevated CK + myoglobinuria → acute kidney injury risk. See AKI nursing reference for full management
- Serum lipase: If fat embolism is suspected; lipemia (fat globules in serum) may be visible
- Urinalysis: Myoglobinuria appears as tea-colored or cola-colored urine with dipstick positive for blood but no RBCs on microscopy
Refer to the nursing lab values cheat sheet for normal reference ranges.
Management
Conservative management
Conservative (non-surgical) management is appropriate for many fractures, particularly non-displaced or minimally displaced fractures with intact neurovascular status.
| Modality | Indication | Nursing care priorities |
|---|---|---|
| Splinting (acute) | Acute immobilization before definitive treatment; swelling anticipated; bivalved cast | Window or bivalve if cast applied acutely; elevate above heart level; neurovascular checks every 30–60 min; teach patient to report numbness, tingling, or increased pain |
| Circumferential cast | Definitive immobilization of stable fractures; applied after swelling subsides | Monitor for cast tightness (swelling may occur); teach cast care: keep dry, no objects inserted under cast; inspect skin at cast edges; monitor for pressure sores |
| Functional brace | Tibial shaft and humeral shaft fractures after initial immobilization phase | Ensure proper fit; teach correct donning and doffing; monitor for skin breakdown and edema |
| Sling | Clavicle fractures, proximal humerus fractures, distal radius fractures in definitive cast | Correct positioning — elbow at 90°; check axilla for pressure sores; reassess fit as swelling resolves |
| Figure-of-8 brace | Clavicle fractures (some centers prefer sling; evidence comparable) | Check axillary skin; ensure brace does not compress neurovascular structures; teach patient to retract shoulders |
Traction
Traction applies a pulling force to reduce and maintain fracture alignment. It is used less frequently today with advances in surgical fixation but remains relevant in specific scenarios (preoperative femur fracture stabilization, pediatric fractures, definitive management in some settings).
| Type | Description | Common use | Nursing care rules |
|---|---|---|---|
| Buck's traction | Skin traction using a boot or tape applied to the lower leg; 5–8 lbs maximum | Hip fracture — temporary pre-operative stabilization; reduce pain from muscle spasm | Check skin integrity under boot daily; weights must hang freely — never rest on bed or floor; maintain counter-traction by keeping foot of bed elevated (Trendelenburg); do not remove without MD order |
| Russell's traction | Skin traction with knee in slight flexion (sling under knee); pull is both horizontal and vertical | Femur fractures; knee fractures | Same as Buck's; assess popliteal pulse and posterior knee skin integrity; knee sling position critical |
| Skeletal traction | Pin through bone (Steinmann pin, Kirschner wire); allows heavier weights (15–35 lbs) | Femur shaft fractures; cervical spine stabilization; unstable pelvic fractures | Pin site care per protocol (chlorhexidine or NS, typically daily); monitor for pin site infection (erythema, drainage, loosening); never remove traction suddenly; weights must hang freely |
Universal traction rules (non-negotiable):
- Weights must always hang freely — never resting on the bed, floor, or chair
- Counter-traction (patient’s body weight against the pull) must be maintained — ensure correct bed position
- Ropes must remain in the pulleys without knots or fraying
- Do not lift weights to move the patient — move the patient toward the direction of pull
Surgical management
| Procedure | Description | Common indications | Nursing considerations |
|---|---|---|---|
| CRIF (closed reduction, internal fixation) | Fracture reduced under fluoroscopy without opening the fracture site; fixation with percutaneous pins or screws | Distal radius fractures, some ankle fractures, pediatric fractures | Smaller incisions; infection risk lower; monitor pin sites; cast or splint post-op |
| ORIF (open reduction, internal fixation) | Surgical incision, direct visualization of fracture, anatomic reduction, fixation with plates/screws/rods | Displaced intra-articular fractures, unstable fractures, open fractures, failed closed reduction | Pre-op: NBM status, consent, IV access, skin assessment; post-op: wound drainage, dressing, drain output, neurovascular checks, DVT prophylaxis, early mobilization as ordered |
| Intramedullary nailing | Rod inserted through the medullary canal of long bones; proximal and distal locking screws | Femur shaft, tibial shaft, humeral shaft fractures | Minimal blood loss compared to plating; assess compartment syndrome (reaming can increase intramedullary pressure); weight-bearing as ordered per nail design |
| Hemiarthroplasty | Replacement of femoral head only with prosthesis; acetabulum preserved | Displaced femoral neck fractures in older adults (>70 years); failed ORIF with AVN | Hip precautions: posterior approach — no flexion >90°, no internal rotation, no adduction past midline; monitor for dislocation signs (sudden pain, external rotation, limb shortening) |
| Total hip arthroplasty (THA) | Replacement of both femoral head and acetabulum | Femoral neck fractures in active older adults; failed hemiarthroplasty; pre-existing osteoarthritis of the hip | Same hip precautions; higher dislocation risk than hemi; falls prevention critical; PT/OT referral; abduction pillow between legs when supine |
| External fixation | Pins through skin into bone, connected by external frame; temporary or definitive | Damage control in polytrauma; open fractures with contamination; pelvic ring disruptions | Pin site care daily; inspect for infection; educate patient on frame — do not adjust nuts/bolts; frame is heavy and awkward, teach safe transfers |
Complications
Complications are the highest-yield content for NCLEX and clinical practice. The nurse who can identify complications early and act decisively saves limbs and lives.
Compartment syndrome
Compartment syndrome is a medical emergency that occurs when pressure within a closed fascial compartment rises to a level that compromises tissue perfusion. Muscle ischemia begins within 4–6 hours of sustained elevated pressure; irreversible damage (Volkmann’s ischemic contracture in the forearm, foot drop from anterior compartment syndrome in the leg) follows within 8–12 hours. Amputation may result if fasciotomy is not performed promptly.
Most common sites: Anterior compartment of the leg (tibial shaft fractures), forearm (Colles’ fracture, supracondylar humeral fractures in children), and any compartment compressed by a tight cast or dressing.
Causes: Fracture (hematoma), crush injury, reperfusion injury after vascular repair, tight cast or dressing, prolonged compression (positioning during surgery, unconsciousness), burns, intraosseous infusion extravasation.
Assessment — the cardinal sign:
Pain with passive stretch that is disproportionate to the injury and unrelieved by opioids is the earliest and most reliable clinical sign of compartment syndrome.
To test passive stretch: gently extend the fingers (for forearm compartments) or dorsiflex the foot (for leg compartments). Severe pain with this maneuver in a post-fracture patient = compartment syndrome until proven otherwise.
Whitesides technique: Compartment pressure measurement using an 18-gauge needle connected to a pressure transducer or mercury manometer. Normal compartment pressure is 0–8 mmHg. Fasciotomy is indicated when:
- Absolute pressure ≥30 mmHg, OR
- Delta pressure (diastolic BP minus compartment pressure) ≤30 mmHg (more clinically relevant threshold)
Nursing actions when compartment syndrome is suspected:
- Notify provider and charge nurse immediately — this is a limb-threatening emergency
- Remove all circumferential dressings, cast padding, and the cast (bivalve or remove entirely)
- Position the affected extremity at heart level — do NOT elevate (elevation reduces arterial perfusion pressure)
- Do NOT apply ice — vasoconstriction worsens ischemia
- Continue neurovascular checks every 15–30 minutes
- Prepare for possible emergent fasciotomy
Fasciotomy: Surgical incision through the skin and fascia to relieve compartment pressure. Post-fasciotomy wounds are left open and managed with wet-to-dry dressings or wound VAC; delayed primary closure or skin grafting occurs after swelling resolves (typically 5–10 days).
Avascular necrosis (AVN)
Avascular necrosis — also called osteonecrosis — is death of bone due to interrupted blood supply. In the context of fractures, it most commonly affects the femoral head (after femoral neck fractures), the humeral head (after proximal humerus fractures), and the scaphoid (after scaphoid waist fractures).
Mechanism in femoral neck fractures: The blood supply to the femoral head travels primarily via the medial circumflex femoral artery, which runs along the femoral neck within the joint capsule. Displacement of a femoral neck fracture stretches or tears this vessel, causing ischemia. Rates of AVN following displaced femoral neck fractures range from 15–30%; Garden III and IV fractures carry the highest risk.
Timeline: AVN typically presents 6–24 months after injury. Patients may be pain-free initially and then develop progressive groin pain as the necrotic bone collapses. X-ray findings are late; MRI is the gold standard for early detection.
Nursing role: Patient education — patients who have undergone ORIF of a femoral neck fracture need to understand the ongoing risk of AVN and the importance of follow-up imaging; symptoms to report (groin pain, limping, decreased range of motion); compliance with weight-bearing restrictions.
Deep vein thrombosis and pulmonary embolism
Fractures activate all three components of Virchow’s triad: vessel wall injury from the fracture itself, venous stasis from immobility, and hypercoagulability from the systemic inflammatory response to injury. Hip and pelvic fractures carry among the highest DVT and PE risk of any clinical scenario.
DVT prophylaxis is mandatory. Evidence-based approaches include:
- Chemical: LMWH (enoxaparin) is first-line; fondaparinux, direct oral anticoagulants (rivaroxaban, apixaban), or warfarin as alternatives
- Mechanical: Sequential compression devices (SCDs) applied to both lower extremities (the unaffected leg at minimum) as long as patient is non-ambulatory; do not apply to a fracture extremity without orthopedic clearance
- Early mobilization: The most effective DVT prevention; initiate as soon as surgically and hemodynamically appropriate
See DVT nursing reference for complete DVT assessment and management, and pulmonary embolism nursing for PE recognition and emergent care.
Delayed union, non-union, and malunion
| Complication | Definition | Contributing factors | Management |
|---|---|---|---|
| Delayed union | Fracture healing taking longer than expected (varies by site — typically >3 months for most long bones) but still progressing | Infection, smoking, malnutrition, diabetes, NSAIDs, corticosteroids, osteoporosis, inadequate immobilization, poor vascular supply, distraction at fracture site | Address modifiable factors (optimize nutrition, smoking cessation, glucose control); continue immobilization; bone stimulator (electrical or ultrasound) may be trialed |
| Non-union | Cessation of the healing process without fracture consolidation; no further healing expected without intervention | Same as delayed union, more severe; hypertrophic (adequate blood supply but insufficient stability) vs atrophic (poor vascularity) | Surgical revision: bone grafting ± exchange nailing; treat infection if present; optimize comorbidities |
| Malunion | Fracture healed in a non-anatomic position (angulation, rotation, or shortening) | Inadequate reduction, inadequate immobilization, patient non-compliance with weight-bearing restrictions | Observation if functional impairment is minimal; corrective osteotomy for significant deformity, limb length discrepancy, or functional limitation |
Infection and osteomyelitis
Open fractures, particularly Gustilo Type IIIB and IIIC, carry substantial infection risk. Osteomyelitis — infection of bone — is one of the most devastating orthopedic complications and is notoriously difficult to eradicate once established, often requiring months of antibiotic therapy and multiple surgical debridements.
Nursing role in infection prevention:
- IV antibiotics administered within 1–3 hours of open fracture; cefazolin for Type I/II; add gentamicin and/or metronidazole for Type III
- Tetanus prophylaxis per protocol (question patient about immunization history)
- Sterile technique for all wound care
- Monitor for signs of wound infection: increasing erythema, warmth, edema, purulent drainage, fever, rising inflammatory markers (WBC, CRP, ESR)
- Report hardware-related symptoms (persistent pain at implant site, wound breakdown) — these may indicate peri-implant infection requiring removal
Heterotopic ossification
Heterotopic ossification (HO) is the formation of bone in abnormal extraskeletal locations — in muscles and soft tissues around fractures or joints. It is most common after hip fractures or arthroplasty, elbow fractures, and traumatic brain injury. Presentation: decreased range of motion, pain, firmness palpable in periarticular tissues at 3–8 weeks post-injury.
Prophylaxis (used in high-risk cases): indomethacin or other NSAIDs for 6 weeks post-op, or single-dose radiation therapy. Nursing: range of motion exercises as ordered to maintain joint function; do not aggressively force passive ROM once HO is established.
Neurovascular injury
Direct injury to nerves and vessels can occur at the time of fracture or during surgical repair. High-yield nerve injuries by fracture location:
| Fracture location | Nerve at risk | Clinical finding |
|---|---|---|
| Proximal humerus / shoulder dislocation | Axillary nerve | Deltoid weakness, numbness over the "regimental badge" area of the lateral upper arm |
| Humeral shaft (midshaft) | Radial nerve | Wrist drop, inability to extend fingers/wrist, numbness dorsum of hand between thumb and index finger |
| Distal humerus / elbow (supracondylar) | Anterior interosseous nerve (branch of median) | "OK" sign abnormality — can't form perfect O (FPL and FDP of index finger weak) |
| Medial epicondyle (elbow) | Ulnar nerve | Ring and little finger numbness, intrinsic hand weakness, claw hand |
| Hip dislocation / posterior acetabulum | Sciatic nerve | Foot drop (peroneal division), posterior leg and foot numbness |
| Fibular neck / knee dislocation | Common peroneal (fibular) nerve | Foot drop, inability to dorsiflex and evert the foot; numbness on dorsum of foot |
| Femoral shaft / hip | Femoral artery | Absent femoral/popliteal/dorsalis pedis pulse; expanding thigh hematoma; hemodynamic instability |
Nursing diagnoses and interventions
| Nursing diagnosis | Related to | Priority interventions | Expected outcomes |
|---|---|---|---|
| Acute pain | Fracture, muscle spasm, soft tissue injury, surgical intervention, edema | Administer prescribed multimodal analgesia (opioids, NSAIDs, acetaminophen, regional blocks); elevate affected extremity; apply ice for first 48–72 hours; position for comfort; use non-pharmacologic strategies; assess pain using validated scale every 4 hours and 30–60 min after analgesics | Patient reports pain ≤3/10 at rest; able to participate in mobilization and rehabilitation |
| Impaired physical mobility | Fracture, cast/traction, prescribed weight-bearing restrictions, pain, post-operative status | Implement physical therapy referral; teach weight-bearing orders (NWB, TTWB, PWB, WBAT, FWB); assist with safe transfers using gait belt; provide appropriate assistive devices (walker, crutches, cane); ensure call light within reach; implement fall prevention protocol | Patient demonstrates safe mobility within weight-bearing restrictions; no fall events |
| Risk for peripheral neurovascular dysfunction | Fracture, edema, tight cast/dressing, surgical swelling, traction | Perform 6-P neurovascular checks every 1–2 hours; compare bilaterally; document findings; report any changes immediately; bivalve or remove cast if tightness develops; never elevate extremity if compartment syndrome is suspected; prepare for fasciotomy if indicated | Neurovascular status remains intact throughout hospitalization |
| Risk for infection | Open fracture, surgical incision, pin sites, disrupted skin integrity | Administer IV antibiotics as ordered; sterile wound care using aseptic technique; monitor wound for erythema, warmth, edema, drainage, odor; check temperature and WBC trends; tetanus prophylaxis as indicated; educate patient on signs of infection | Wound heals without signs of infection; afebrile; WBC trending down; negative cultures |
| Ineffective peripheral tissue perfusion | Vascular injury associated with fracture, DVT, arterial occlusion | Monitor peripheral pulses bilaterally; assess capillary refill, skin temperature, color; DVT prophylaxis (SCDs, anticoagulation as ordered); early ambulation; maintain adequate hydration; report new swelling, redness, warmth, or absent pulses | Peripheral pulses present and equal; no DVT or PE; adequate capillary refill bilaterally |
| Deficient knowledge | Unfamiliarity with fracture management, cast/traction care, weight-bearing restrictions, complications | Assess learning readiness and barriers; teach cast/splint care, weight-bearing restrictions, assistive device use, and when to seek emergency care (compartment syndrome signs); provide written instructions; verify understanding with return demonstration; involve family/caregiver in teaching | Patient/family correctly demonstrate cast care, verbalizes weight-bearing restrictions, and identifies emergency symptoms |
Pain management
Multimodal analgesia is the standard approach for fracture pain — combining agents with different mechanisms to achieve superior pain control with lower doses of each agent and reduced opioid-related adverse effects.
Components of multimodal analgesia:
- Acetaminophen (scheduled, not PRN): 1,000 mg q6h (max 4 g/day in healthy adults; reduce in hepatic impairment or heavy alcohol use)
- NSAIDs (if not contraindicated): ketorolac IV/IM in the acute setting; caution in renal impairment, GI history, elderly patients; note: some evidence that NSAIDs may impair fracture healing — discuss with orthopedic provider
- Regional nerve blocks: peripheral nerve blocks (femoral nerve block, adductor canal block for hip/knee fractures; fascia iliaca block for hip fractures; brachial plexus block for upper extremity) provide excellent analgesia without systemic opioid effects; epidural analgesia for thoracic and lumbar fractures
- Opioids: IV PCA (patient-controlled analgesia) in the acute setting; transition to oral opioids as tolerated; use lowest effective dose; monitor sedation and respiratory status
Opioid nursing monitoring:
- Sedation scale (Pasero Opioid-Induced Sedation Scale — POSS): Score 1 (awake, alert) is acceptable; Score 3 (difficult to arouse) requires dose reduction; Score 4 (unarousable) = respiratory emergency
- Respiratory rate and SpO₂ per protocol (hourly minimum in first 24 hours of PCA)
- Constipation prophylaxis: every opioid prescription warrants a laxative order (senna, docusate); do not wait for constipation to develop
- Assess for urinary retention: opioids reduce detrusor tone; monitor urinary output and bladder scan PRN
Non-pharmacologic strategies: Elevation of affected extremity (reduces edema and thereby pain); ice or cold therapy for first 48–72 hours (reduces inflammation; protect skin from frostbite — wrap in cloth; 20 minutes on, 20 minutes off); positioning with pillows; distraction and relaxation techniques; transcutaneous electrical nerve stimulation (TENS) in the rehabilitation phase.
Mobility and rehabilitation
Weight-bearing classifications
Weight-bearing orders from the orthopedic surgeon are based on fracture stability, fixation type, and bone quality. Nurses must understand these orders precisely to prevent re-injury, hardware failure, or non-union.
| Abbreviation | Full term | Definition | Nursing implications |
|---|---|---|---|
| NWB | Non-weight-bearing | No weight on the affected extremity at all; no foot contact with floor | Requires crutches (upper extremity strength permitting) or wheelchair; teach crutch technique; assess upper extremity strength (elderly patients often cannot manage non-weight-bearing on crutches) |
| TTWB | Toe-touch weight-bearing (also called touch-down weight-bearing) | Toes may touch floor for balance only; no weight transferred through the limb | Easiest to demonstrate with a bathroom scale — no more than a few pounds; still requires crutches or walker |
| PWB | Partial weight-bearing | A specified percentage of body weight (typically 25–50%) may be applied; often prescribed as "PWB 50%" | Use a bathroom scale to teach patient how much weight 50% feels like; requires walker or crutches; monitor for pain and hardware complications |
| WBAT | Weight-bearing as tolerated | Patient may bear as much weight as is comfortable; pain is the guide | Encourage mobilization; assist with assistive device as needed; encourage incremental increases |
| FWB | Full weight-bearing | Full weight on the extremity; assistive device for balance or confidence only | Continue fall prevention; progress to ambulating without device as strength and balance improve |
Hip precautions after arthroplasty
Following total hip arthroplasty or hemiarthroplasty via the posterior approach (the most common surgical approach), the following precautions reduce the risk of prosthetic dislocation:
- No hip flexion greater than 90 degrees — do not bend forward from the waist past a right angle; raised toilet seat required; do not sit on low chairs or sofas
- No internal rotation of the operative hip — do not turn the toes inward; do not cross the legs
- No adduction past the midline — do not cross the legs or let the knee fall inward; abduction pillow between legs when supine
Signs of hip dislocation: sudden severe groin pain, shortened and externally rotated leg (or internally rotated, depending on direction of dislocation), inability to bear weight. Dislocation is a surgical emergency. Do not attempt to relocate. Immobilize and notify surgeon.
Note: some surgeons use the anterior approach, which has different (or no) precautions and a different dislocation risk profile. Always confirm the surgeon’s specific precautions in the operative note and postoperative orders.
Transfer techniques and fall prevention
Fracture patients — particularly elderly hip fracture patients — are at extremely high fall risk. Fall prevention strategies:
- Call light within reach at all times
- Bed in lowest position; brakes locked
- Non-slip footwear
- Clear pathway to bathroom; bedside commode if needed
- Two-person transfer for the first 24–48 hours post-op
- PT/OT consultation on day of or day after surgery
- Cognitive assessment (post-op delirium is common in elderly fracture patients — see below)
- Hourly rounding
Post-operative delirium is a frequent complication in elderly patients after hip fracture surgery. Risk factors: age, pre-existing cognitive impairment, sleep deprivation, pain, opioid use, urinary retention, constipation, unfamiliar environment. Use a validated tool (CAM — Confusion Assessment Method) to screen daily. Non-pharmacologic interventions are first-line: reorientation, consistent nursing staff, natural light exposure, sleep protocols, hearing aids and glasses in place, early mobilization.
Patient education
Cast and splint care at home
Patients discharged with a cast or splint require comprehensive education:
- Keep the cast dry — waterproof cast liners are available; cover with plastic bag for showering; no submersion
- Do not insert objects under the cast — coat hangers and pencils to relieve itching cause skin breakdown and are a route for infection
- Elevate the extremity — above heart level for first 48–72 hours after discharge to minimize swelling
- Check circulation daily — compare fingers/toes to the unaffected side; report numbness, tingling, increased pain, or skin discoloration immediately
- Inspect the cast edges — pad with moleskin or soft cloth if cast edges are rough; report any drainage or foul odor soaking through the cast
When to seek emergency care
Patients must understand that the following warrant an immediate return to the ED — not a call to the office tomorrow:
- Numbness or tingling in fingers or toes that is new or worsening
- Increasing pain not controlled by prescribed medications, especially pain that worsens when moving the fingers or toes
- Fingers or toes that are pale, blue, or cold compared to the other hand/foot
- Cast feels too tight and cannot be relieved by elevation
- Sudden severe joint pain post-arthroplasty (may indicate prosthetic dislocation)
- Shortness of breath, chest pain, or leg swelling (may indicate DVT or PE)
Osteoporosis prevention in patients with pathologic fractures
Patients who fracture with minimal trauma should be evaluated for underlying osteoporosis. The Fracture Liaison Service (FLS) model provides systematic post-fracture osteoporosis assessment. Nursing education:
- Calcium (1,200 mg/day in women over 50) and vitamin D (800–1,000 IU/day) supplementation
- Weight-bearing exercise after healing is complete
- Smoking cessation, limit alcohol intake
- Discussion of bisphosphonate therapy — start after acute fracture healing; do not start IV zoledronate within 2 weeks of surgery (may interfere with fracture healing in some data)
- DEXA scan referral if not already done
Weight-bearing compliance
Non-compliance with weight-bearing restrictions is a leading cause of hardware failure and re-fracture. Teach patients:
- What weight-bearing as tolerated means in practice (use a bathroom scale demonstration)
- Why the restrictions exist — the hardware is not as strong as native bone; it needs time for bone to grow around it
- Signs of hardware failure: sudden increase in pain, deformity, clicking sensation, inability to bear weight that was previously tolerated
NCLEX-style practice questions
Question 1: Compartment syndrome recognition
Scenario: A 28-year-old male is 4 hours post-ORIF of a tibial shaft fracture. He has been receiving IV morphine 4 mg every 4 hours via PRN order. His most recent dose was 90 minutes ago. He calls his nurse reporting severe pain (9/10) in his lower leg. He describes the pain as burning and states it is worse when the nurse gently moves his toes upward. His toes are slightly pale compared to the other foot, and he reports tingling in his foot. His most recent vital signs: BP 128/82, HR 104, RR 16, SpO₂ 99%.
Which action by the nurse is the highest priority?
A. Administer another dose of IV morphine for pain control B. Notify the surgeon immediately and prepare to remove the dressing and splint C. Elevate the leg above the level of the heart to reduce edema D. Apply a cold pack to the lower leg and reassess in 30 minutes
Answer: B
Rationale: This patient has the hallmark presentation of compartment syndrome: pain disproportionate to the injury, unrelieved by opioids, and worsened by passive stretch of muscles in the affected compartment (pain with passive dorsiflexion of the toes stretches the anterior compartment muscles). Paresthesia and pallor are additional warning signs. The immediate priority is to notify the surgeon and remove all circumferential dressings — NOT to administer more analgesics (A: analgesics do not treat the underlying pathology and will mask worsening symptoms). Elevation (C) is contraindicated in compartment syndrome — it reduces the arteriovenous gradient and worsens ischemia. Cold packs (D) cause vasoconstriction and worsen ischemia; delay in acting risks irreversible muscle damage. Time to fasciotomy is critical.
Question 2: Fat embolism syndrome
Scenario: A 35-year-old female sustained a femur shaft fracture in a motor vehicle collision 48 hours ago. She underwent intramedullary nailing the same day without complications. This morning, the nursing assistant reports the patient seems confused and asked where she was. On assessment, the nurse notes: SpO₂ 88% on room air (was 98% yesterday), respiratory rate 28, temperature 38.8°C, HR 118, and a petechial rash over the axillae and anterior chest. Chest X-ray shows bilateral infiltrates.
Which condition is most consistent with this presentation, and what is the priority nursing action?
A. Hospital-acquired pneumonia; obtain sputum culture and administer antibiotics B. Pulmonary embolism; prepare the patient for emergent CT pulmonary angiography C. Fat embolism syndrome; apply high-flow oxygen and notify the provider immediately D. Acute respiratory distress syndrome (ARDS) from pulmonary contusion; prepare for intubation
Answer: C
Rationale: The clinical picture is consistent with fat embolism syndrome: onset 24–72 hours post long bone fracture, the classic Gurd triad of hypoxemia (SpO₂ 88%), neurologic changes (confusion), and petechial rash (axillae, anterior chest). The petechial rash is the pathognomonic finding that distinguishes FES from PE (B) — PE does not produce a petechial rash. FES has a more gradual onset than PE, which typically presents suddenly. While ARDS (D) may complicate FES and may ultimately require intubation, the immediate priority is supplemental oxygen. HAP (A) does not explain the acute onset, petechial rash, or neurologic changes. Priority actions: high-flow oxygen, elevate HOB, IV access, continuous monitoring, notify provider, prepare for possible intubation.
Question 3: Hip fracture and AVN risk
Scenario: A 72-year-old woman presents after a fall at home. X-ray confirms a displaced femoral neck fracture (Garden IV). The orthopedic surgeon discusses surgical options with the patient and family, recommending hemiarthroplasty rather than ORIF with screws.
Which explanation best describes why arthroplasty is preferred over ORIF in this patient?
A. Internal fixation hardware cannot withstand the mechanical load of a femoral neck fracture in elderly patients B. Arthroplasty provides immediate full weight-bearing ability, whereas ORIF requires a prolonged non-weight-bearing period C. The displaced femoral neck fracture has likely disrupted blood supply to the femoral head, making avascular necrosis a high risk with fixation alone D. ORIF is contraindicated in patients over age 70 due to increased infection risk from metallic implants
Answer: C
Rationale: The femoral head receives its blood supply primarily from the medial circumflex femoral artery, which travels along the femoral neck within the joint capsule. A displaced femoral neck fracture (Garden III–IV) disrupts this vessel. Even if anatomic reduction and internal fixation are achieved, the already-compromised blood supply frequently leads to AVN of the femoral head in 15–30% of displaced fractures — meaning the patient may initially do well but later develop femoral head collapse requiring salvage arthroplasty. Arthroplasty removes the femoral head entirely, eliminating this risk. While earlier weight-bearing is often possible after arthroplasty (B), this is a secondary consideration. Option A is incorrect — fixation constructs are mechanically sound; the failure mode is biological (AVN), not mechanical. Option D is incorrect — there is no absolute age contraindication to ORIF.
Question 4: Traction nursing care
Scenario: A nurse is caring for a patient in Buck’s traction applied to the right leg for a hip fracture while awaiting surgery. During routine assessment, the nurse notices that the weight bag is resting on the footboard of the bed, and the patient has repositioned himself to reach his water pitcher, sliding up in bed.
What is the priority nursing action?
A. Remove the traction and reapply it with the patient in correct position B. Reposition the patient toward the foot of the bed, ensure the weights hang freely, and reinforce positioning education C. Reduce the weight by 50% until the patient can be repositioned by two nurses D. Document the finding and request a physical therapy consultation for safe transfer technique
Answer: B
Rationale: Traction is therapeutic only when applied correctly. Two key rules are violated in this scenario: (1) the weights are resting on the footboard and are not hanging freely — this eliminates the traction force entirely; and (2) the patient has slid up in bed, eliminating counter-traction (his body weight resisting the pull) — this also eliminates effective traction. The nurse must reposition the patient toward the foot of the bed to restore counter-traction and ensure the weights hang freely. Option A is incorrect — Buck’s traction should not be removed without a physician order; it can be briefly relieved for care but the nurse cannot discontinue it. Option C is incorrect — reducing weight requires a physician order and is not appropriate for a positioning problem. Option D is incorrect — documentation and PT referral are appropriate adjuncts but do not address the immediate problem of non-functional traction.
Question 5: Post-op hip precautions
Scenario: A 78-year-old man is on post-operative day 1 following a right total hip arthroplasty via posterior approach for a displaced femoral neck fracture. The nurse enters the room to find the patient sitting in the bedside chair with his right knee crossed over his left knee, leaning forward to put on his socks.
Which complication is this patient at immediate risk for, and what is the nurse’s priority action?
A. Deep vein thrombosis; apply sequential compression devices and notify the provider B. Wound infection; assess the incision for signs of dehiscence and contamination C. Prosthetic hip dislocation; stop the patient immediately, have him uncross his legs and sit back, and provide hip precaution education D. Peroneal nerve injury; assess dorsiflexion strength and sensation over the dorsum of the foot
Answer: C
Rationale: This patient is violating two posterior hip precautions simultaneously: adduction past the midline (right knee crossed over left knee) and hip flexion greater than 90 degrees (leaning forward to put on socks). Both actions, especially in combination, significantly increase the risk of posterior prosthetic hip dislocation. The nurse must stop the activity immediately, reposition the patient, and reinforce hip precautions. Dislocation presents with sudden severe pain, a shortened and externally rotated leg, and inability to bear weight. It is a surgical emergency. DVT prophylaxis (A) is important ongoing care but is not the acute priority here. Wound infection (B) is not directly caused by this positioning. Peroneal nerve injury (D) can occur post-arthroplasty from stretch or compression but is not the risk created by this specific patient action.
Question 6: Open fracture classification
Scenario: A construction worker is brought to the ED after a concrete block fell on his right lower leg. He has a 15 cm wound over the tibia with bone visible in the wound, extensive muscle damage, and significant contamination with concrete dust and debris. A vascular surgery consult has been requested because the dorsalis pedis pulse is absent on Doppler assessment. X-ray confirms a comminuted tibial shaft fracture.
Which Gustilo-Anderson classification applies to this fracture, and what is the nurse’s most time-sensitive intervention?
A. Type IIIA — apply a sterile dressing and administer cefazolin IV immediately B. Type IIIB — prepare the patient for emergent OR and initiate broad-spectrum antibiotics including coverage for gram-negative organisms C. Type IIIC — initiate broad-spectrum IV antibiotics and prepare for emergent vascular surgery; absent pulse is the defining feature D. Type II — contamination is the primary feature; administer penicillin and schedule elective OR
Answer: C
Rationale: The defining feature of Gustilo Type IIIC is an open fracture of any size with arterial injury requiring vascular repair. The absent dorsalis pedis pulse confirmed on Doppler indicates vascular injury — this is the key differentiator between IIIA/B and IIIC. The wound characteristics (>10 cm, extensive muscle damage, high contamination) already place this in the Type III category; the vascular injury elevates it to IIIC. Time-sensitive interventions: IV antibiotics immediately (cefazolin + gentamicin for Type III; add metronidazole if significant fecal or soil contamination); emergent vascular surgery consultation; prepare for combined orthopedic and vascular OR. The limb ischemia clock is running — every minute of delay increases the risk of irreversible ischemia, fasciotomy requirement, and amputation. Option A (IIIA) and B (IIIB) are incorrect because the absent pulse defines IIIC. Option D is incorrect — Type II wounds are 1–10 cm without extensive soft tissue damage, and the antibiotic choice is wrong.
Key takeaways for clinical practice
Fracture nursing integrates orthopedic assessment skills, surgical care, complication recognition, and patient education into a high-stakes clinical specialty. The most important principles:
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Neurovascular assessment is your primary safety tool. The 6 Ps performed consistently and documented accurately are how you catch compartment syndrome, vascular injury, and cast complications before they become irreversible.
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Pain out of proportion + pain with passive stretch = compartment syndrome until proven otherwise. Do not give more analgesia. Remove the cast. Call the surgeon. This is a limb-threatening emergency that moves faster than most other complications.
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Fat embolism syndrome and pulmonary embolism are clinical distinctions that matter. FES develops gradually, 24–72 hours post-fracture, with the petechial rash triad. PE develops suddenly. Both require oxygen, provider notification, and rapid escalation.
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Hip fracture is as much a medical problem as a surgical one. The perioperative mortality and morbidity of hip fractures are driven by the patient’s age and comorbidities, not just the fracture. DVT prophylaxis, delirium prevention, early mobilization, and pressure injury prevention are equally important as the surgical repair.
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Hip precautions post-arthroplasty are your responsibility to reinforce at every interaction. One dislocation is a setback of weeks. Reinforce, demonstrate, and verify understanding.
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Open fractures require antibiotics within 1–3 hours. This is a time-sensitive intervention analogous to antibiotics in sepsis. Know the protocol and act on it immediately.
For nursing students working through musculoskeletal content, review osteoporosis nursing for fracture risk and prevention, osteoarthritis nursing for arthroplasty background, DVT nursing reference for thromboembolic complications, pulmonary embolism nursing for the PE differential, and AKI nursing reference for rhabdomyolysis and crush injury sequelae. For NCLEX preparation strategies, see NCLEX study tips.