Med-Surg · Musculoskeletal
Fractures, Compartment Syndrome & Joint Disease
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current drug references.
1. Overview and Pathophysiology
A fracture is a break in bone continuity. Healing stages: hematoma → soft callus → hard callus → remodeling. Complications include infection (open fractures), VTE, delayed union, and —rising pressure in a closed muscle compartment that cuts off perfusion.
Osteoarthritis (OA): degenerative “wear-and-tear,” usually asymmetric, worse with activity. Rheumatoid arthritis (RA): autoimmune, symmetric synovitis, morning stiffness often > 1 hour, systemic features.
Total joint arthroplasty restores function but requires dislocation precautions and VTE prevention.
2. Causes and Risk Factors
- Trauma, osteoporosis, malignancy, repetitive stress
- Compartment syndrome: tight casts, crush injury, reperfusion, burns, fractures (tibia/forearm classic)
- OA: age, obesity, prior injury; RA: female sex, smoking, genetic factors
3. Signs and Symptoms
- Fracture: pain, deformity, crepitus, swelling, loss of function, guarding
- Neurovascular compromise—6 P’s: Pain, Pallor, Paresthesia, Paralysis, Pulselessness, Poikilothermia
- Compartment syndrome: pain out of proportion, pain on passive stretch, escalating need for opioids; pulselessness is late
- Fat embolism (long bones, 24–72 h): dyspnea, confusion, petechiae on chest/axilla
- OA: activity pain, Heberden/Bouchard nodes; RA: boggy synovitis, ulnar deviation late, fatigue
4. Diagnostics and Labs
Lab reference ranges vary by laboratory. Always use your facility’s ranges.
| Test | Note | Nursing relevance |
|---|---|---|
| X-ray / CT / MRI | Fracture definition | Immobilize before/after imaging per protocol |
| Calcium, vitamin D | Bone health | Osteoporosis workup |
| ESR / CRP / RF / anti-CCP | Inflammation / RA | Disease activity |
| Uric acid | Gout differential | Not always elevated in acute flare |
| CK | Rhabdo / crush | Kidney protection |
| Pre-op CBC, coags | Surgery | Bleeding risk |
5. Priority Nursing Assessments
- Neurovascular checks distal to injury frequently
- Cast/splint fit: tightness, odor, drainage, hot spots
- Traction: weights hanging freely, body alignment, pin sites
- Pain character (unrelieved? passive stretch?)
- VTE signs; lung sounds (fat embolism / PE)
- Functional ability, fall risk, self-care after arthroplasty
6. Priority Nursing Interventions
- RICE principles as ordered; immobilize joints above/below fracture
- Suspected compartment syndrome: notify provider STAT; keep limb at heart level (not elevated high); loosen dressings / bivalve cast per order—do not delay
- Open fracture: cover with sterile dressing, tetanus status, IV antibiotics as ordered
- Fat embolism: O₂, high Fowler’s, rapid response, support ABCs
- Hip arthroplasty (posterior approach teaching classic): avoid flexion > 90°, adduction, internal rotation; abduction pillow; raised toilet seat—confirm approach-specific orders
- Early mobility, anticoagulants, SCDs; pain control timed before PT
- Amputation: monitor hemorrhage; prone positioning to limit hip contracture per protocol; validate phantom pain
7. Medications
| Class / examples | Role | Nursing considerations |
|---|---|---|
| NSAIDs | Pain/inflammation | GI bleed, kidney, CV risks |
| Opioids | Acute severe pain | Sedation/RR; constipation prophylaxis |
| Anticoagulants | VTE prevention | Bleeding teaching |
| Bisphosphonates (alendronate) | Osteoporosis | Full glass water, upright 30 min, empty stomach |
| Methotrexate | RA DMARD | Folic acid, no alcohol, teratogenic, CBC/LFT monitor |
| Biologics | RA | Infection screening (TB); live vaccine caution |
| Colchicine / allopurinol | Gout | Allopurinol is preventive—not acute-only; hydrate |
| Antibiotics | Open fractures / osteomyelitis | Timely dosing |
8. Patient Education
- Cast care: keep dry, don’t insert objects, report numbness/color change/increasing pain
- Weight-bearing status exactly as ordered
- Hip precautions demo with teach-back
- RA: pace activity, medication adherence, report infection on immunosuppressants
- Osteoporosis: calcium/vit D, weight-bearing exercise, fall proofing home
- PT/OT participation is treatment, not optional extras
9. Complications
- Compartment syndrome → rhabdomyolysis, renal failure, limb loss
- Fat embolism, PE/DVT
- Osteomyelitis, avascular necrosis
- Dislocation of prosthesis; malunion
- NSAID nephropathy; methotrexate toxicity
10. Memory Aids
- “6 P’s” for neurovascular status
- “Pain on passive stretch = compartment until proven otherwise”
- “Heart level, not sky high” for suspected compartment syndrome
- “RA = Symmetric & Systemic; OA = One-sided & Overuse”
- “Alendronate: water, upright, wait”
11. NCLEX-Style Practice Questions
1. Forearm cast; severe pain unrelieved by morphine, worse with passive finger extension. Priority?
A. Elevate arm above the heart and wait 1 hour
B. Notify the provider immediately
C. Give another opioid only and chart
D. Apply ice and ignore neuro checks
Answer: B. Classic compartment syndrome cues—urgent fasciotomy may be needed. Elevation above the heart can worsen ischemia.
2. Which statement after posterior hip replacement needs more teaching?
A. “I’ll use a raised toilet seat.”
B. “I’ll keep a pillow between my knees as instructed.”
C. “I’ll cross my legs when I sit.”
D. “I won’t bend way down to tie sneakers.”
Answer: C. Crossing legs adducts the hip and risks dislocation.
3. Petechiae on the chest, confusion, and dyspnea 36 hours after femoral fracture suggest:
A. Simple constipation
B. Fat embolism syndrome
C. Only anxiety
D. Hypothyroidism
Answer: B. Triad timing after long-bone fracture is classic teaching.
4. Correct alendronate instruction?
A. Take with coffee and lie down
B. Take with a full glass of water on an empty stomach and remain upright 30 minutes
C. Crush and mix with calcium carbonate simultaneously always
D. Take only at bedtime lying flat
Answer: B. Reduces esophagitis risk.
5. Difference emphasizing RA vs OA?
A. RA is always unilateral DIP only
B. RA is typically symmetric with prolonged morning stiffness and systemic symptoms
C. OA always has positive anti-CCP
D. OA never relates to obesity
Answer: B. Pattern recognition for exam and clinical triage.
References
MedlinePlus. (n.d.). Fractures. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/fractures.html
MedlinePlus. (n.d.). Rheumatoid arthritis. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/rheumatoidarthritis.html
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page
Torlincasi, A. M., Lopez, R. A., & Waseem, M. (2023). Acute compartment syndrome. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448124/
Sen, R., & Hurley, J. A. (2023). Osteoarthritis. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482326/