Musculoskeletal Disorders

Fractures & Types

Know the types, the neurovascular checks, and the life-threatening complications.

Closed (Simple)

Bone breaks but skin remains intact

Open (Compound)

Bone pierces through the skin — HIGH infection risk. Cover with sterile dressing.

Comminuted

Bone shatters into multiple fragments

Greenstick

Incomplete fracture — bone bends and cracks on one side only. Most common in children.

Spiral

Fracture line twists around bone. In young children → red flag for possible abuse.

Pathologic

Fracture through bone weakened by disease (osteoporosis, cancer)

Stress

Hairline crack from repetitive force (runners, military). Pain worsens with activity.

Neurovascular Assessment — The 5 P's of Circulation

• Pain — location, severity, does it worsen?
• Pulse — check distal pulses (pedal, radial)
• Pallor — color of skin distal to injury
• Paresthesia — numbness or tingling?
• Paralysis — can the patient move fingers/toes?

Compartment Syndrome

A surgical emergency — the #1 most tested musculoskeletal complication.

Compartment syndrome occurs when pressure builds within a closed muscle compartment, compressing blood vessels and nerves. Without intervention, it leads to permanent tissue death within 4–6 hours.

The 6 P's of Compartment Syndrome

• Pain — out of proportion to the injury, NOT relieved by opioids, worsens with passive stretching. THIS IS THE EARLIEST SIGN.
• Pressure — compartment feels tight and swollen on palpation
• Paresthesia — numbness, tingling
• Pallor — skin becomes pale or cyanotic
• Pulselessness — LATE sign (by this point, damage may be irreversible)
• Paralysis — LATE sign

Nursing Actions — IMMEDIATE

• Notify the provider immediately — this is an emergency
• Remove or loosen the cast/dressing — bivalve the cast (cut it in half)
• Do NOT elevate the limb — this further decreases arterial perfusion. Keep at heart level.
• Prepare for fasciotomy — surgical opening of the compartment to release pressure (definitive treatment)
• Monitor neurovascular status continuously

Fat Embolism Syndrome

Occurs 24–72 hours after long bone fractures — know the unique sign.

Fat globules from bone marrow enter the bloodstream after a fracture, travel to the lungs, and cause respiratory distress. Most common after femur, tibia, and pelvis fractures.

Signs & Symptoms — "FAT"

• Fever
• Altered mental status — restlessness, confusion, agitation (often the FIRST sign)
• Tachypnea — dyspnea, hypoxemia
• Petechial rash — across the chest, axillae, and conjunctivae. This is the HALLMARK and UNIQUE sign of fat embolism (not seen in PE).
• Tachycardia, decreased SpO₂

Nursing Interventions

• Administer high-flow oxygen
• Position upright (improves respiratory function)
• Monitor ABGs and SpO₂
• Prepare for intubation if severe
• Supportive care — there is no specific treatment
• Prevention: immobilize fractures early and handle gently

Cast & Traction Care

Know the do's and don'ts — these are heavily tested.

Cast Care — "THE CAST"

• Temperature — monitor for fever (sign of infection)
• Hot spots and odor — indicate infection under the cast
• Elevate above heart level for first 24–48 hours (reduces swelling)
• Circulation checks — color, capillary refill, pulse, sensation, movement (every 15–30 min initially)
• Avoid getting cast wet (compromises integrity). Use plastic covering for bathing.
• Swelling monitoring — if fingers/toes become swollen, numb, or blue → notify provider
• Teach patient: Do NOT insert objects to scratch inside the cast (risk of skin breakdown and infection). Use a blow dryer on cool setting for itching.

Traction Care

• Maintain correct weight — do NOT remove or add weight. Weights should hang freely and never rest on the floor.
• Ropes and pulleys hang freely — no kinks, knots, or obstructions
• Maintain body alignment — patient should not slide down in bed
• Pin site care (skeletal traction): clean with normal saline or per facility protocol. Monitor for infection (redness, drainage, warmth, odor).
• Countertraction — the patient's body weight provides countertraction. Do NOT lift weights to reposition.
• Assess neurovascular status frequently
• Encourage ROM exercises on unaffected extremities
• Prevent skin breakdown (inspect pressure points)

Hip Fractures

Most common in elderly patients with osteoporosis — know the pre-op and post-op care.

Hip fractures are a leading cause of morbidity and mortality in the elderly. Most are caused by falls combined with osteoporosis. Intracapsular fractures carry a high risk for avascular necrosis. Treatment is almost always surgical.

Signs of Hip Fracture

• Severe pain in the hip/groin area
• Affected leg is shortened and externally rotated — classic finding
• Unable to bear weight
• Swelling and bruising

Preoperative Care

• Pain management
• Buck's traction (skin traction) may be applied to reduce muscle spasms while waiting for surgery
• NPO for surgery
• Monitor for complications: DVT, fat embolism, hemorrhage

Postoperative — Hip Precautions (Posterior Approach)

• Do NOT cross legs (no adduction)
• Do NOT bend hip >90 degrees
• Do NOT internally rotate the hip
• Do NOT pivot on the affected leg
• Use an abduction pillow between legs when in bed
• Use a raised toilet seat, long-handled reacher, sock aid
• Avoid low chairs, bending to tie shoes
• Turn to the unaffected side (or per surgeon orders)

Joint Replacement (Total Hip & Knee Arthroplasty)

DVT prevention is the #1 priority for both surgeries.

Total Hip Replacement (THA)

See Hip Precautions above. Same protocol applies.

Total Knee Replacement (TKA)

• NO pillow under the knee — causes flexion contracture
• CPM machine (continuous passive motion) — promotes joint mobility, prevents stiffness. Started within 24 hours post-op. Gradually increase ROM per protocol.
• Ice therapy (cryotherapy) for swelling and pain
• Elevate leg when sitting
• PT exercises are critical: quad sets, ankle pumps, straight-leg raises

Priority for Both Surgeries

• DVT/PE prevention — #1 complication concern. SCDs, anticoagulants (enoxaparin, warfarin), early ambulation, ankle pumps.
• Infection monitoring: fever, wound drainage, redness, increasing pain
• Pain management (multimodal approach)
• Monitor for blood loss (may need transfusion)
• Early mobility with PT/OT

Osteoporosis

Silent disease until a fracture occurs — prevention and bisphosphonate teaching are key.

Osteoporosis is a metabolic bone disease characterized by decreased bone density and increased fracture risk. It is most common in postmenopausal women due to estrogen loss. The hip, spine, and wrist are the most common fracture sites.

Risk Factors

• Postmenopausal women (especially Caucasian and Asian)
• Sedentary lifestyle
• Smoking, excessive alcohol, high caffeine intake
• Long-term corticosteroid use
• Low calcium and vitamin D intake
• Family history, low body weight, small frame

Diagnosis

• DEXA scan (dual-energy X-ray absorptiometry) — gold standard. T-score ≤ -2.5 = osteoporosis.

Prevention & Treatment

• Calcium: 1,000–1,200 mg/day (dairy, leafy greens, fortified foods)
• Vitamin D: 600–800 IU/day (needed for calcium absorption)
• Weight-bearing exercise: walking, dancing, resistance training
• Avoid smoking, excessive alcohol, high caffeine
• Fall prevention measures

Osteoarthritis (OA) vs Rheumatoid Arthritis (RA)

Degenerative vs autoimmune — know the key differences.

TypeOA

Degenerative (wear and tear)

TypeRA

Autoimmune / Inflammatory

OnsetOA

Gradual, usually age >50

OnsetRA

Can occur at any age (30–60 common)

Joint involvementOA

Asymmetric — weight-bearing joints (hips, knees, spine)

Joint involvementRA

Symmetric — small joints first (hands, wrists, feet) bilaterally

StiffnessOA

Brief (<30 min), worsens with activity

StiffnessRA

Prolonged (>30 min to hours), improves with movement

Systemic?OA

NO — localized to joints only

Systemic?RA

YES — fatigue, fever, weight loss, organ involvement

Joint findingsOA

Heberden's nodes (DIP), Bouchard's nodes (PIP), crepitus

Joint findingsRA

Swan neck deformity, ulnar deviation, boutonniere deformity

LabsOA

Normal

LabsRA

Positive RF, elevated ESR and CRP

TreatmentOA

Acetaminophen first-line, NSAIDs, weight loss, PT, joint replacement

TreatmentRA

DMARDs (methotrexate = first-line), NSAIDs, corticosteroids, biologics

Amputation

Phantom limb pain is real — and know the positioning to prevent contractures.

Immediate Post-Op Priorities

• Hemorrhage — #1 immediate concern. Keep tourniquet/hemostats at the bedside.
• Elevate residual limb for the first 24 hours (reduces swelling)
• After 24 hours: position flat — do NOT keep elevated (causes flexion contracture)
• Prone positioning for 30 minutes several times a day (prevents hip flexion contracture for AKA)
• No prolonged hip or knee flexion (no pillows under the residual limb after 24 hrs)

Phantom Limb Pain

Sensation or pain felt in the amputated limb. It is REAL — not imagined. Do NOT dismiss the patient's pain.

• Management: gabapentin/pregabalin, mirror therapy, TENS unit, distraction, massage of the residual limb

Residual Limb Care

• Wrap with elastic bandage in figure-8 pattern (promotes shrinkage and shaping for prosthesis fitting)
• Rewrap every 4–6 hours and when loose
• Inspect daily for skin breakdown, redness, drainage
• Emotional support — body image changes, grief process

Osteomyelitis

Bone infection — usually from an open fracture, surgery, or bloodstream.

Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus. It can result from open fractures, surgical procedures, or hematogenous spread.

Signs & Symptoms

• Fever, chills, malaise
• Pain at the bone site (constant, not relieved by rest)
• Redness, warmth, swelling over the affected bone
• Purulent drainage if near the skin surface
• Elevated WBC, ESR, CRP

Treatment

• Long-term IV antibiotics — typically 4–6 weeks (often via PICC line)
• Wound care, possible surgical debridement
• Immobilize affected extremity
• Blood cultures and wound cultures before starting antibiotics
• Monitor for complications: pathologic fracture, sepsis, chronic osteomyelitis

Key Medications

The musculoskeletal medications most commonly tested on the exam.

Alendronate (Fosamax)Osteoporosis

Bisphosphonate. AM, empty stomach, full glass water, upright 30 min. Risk: esophagitis, jaw osteonecrosis.

Calcium + Vitamin DOsteoporosis prevention

Ca²⁺ 1,000–1,200 mg/day. Vit D 600–800 IU/day. Take Ca²⁺ with food. Separate from iron.

MethotrexateRA — first-line DMARD

Immunosuppressant. Monitor CBC, liver function. Teratogenic. Take folic acid. Avoid alcohol.

NSAIDs (ibuprofen)OA, RA, inflammation

Take with food. Monitor for GI bleeding. Avoid in renal disease. Avoid pre-op.

AcetaminophenOA — first-line

No anti-inflammatory effect. Max 3–4 g/day. Hepatotoxic in excess. Avoid with liver disease.

AllopurinolGout prevention

Lowers uric acid. Increase fluids 2–3 L/day. Do NOT start during acute attack.

ColchicineGout — acute attack

Anti-inflammatory. Side effects: GI (nausea, diarrhea). Stop if severe GI symptoms.

GabapentinPhantom limb pain

Neuropathic pain. Side effects: drowsiness, dizziness. Do not stop abruptly.

Enoxaparin (Lovenox)DVT prophylaxis

LMWH. SubQ in abdomen. Do NOT aspirate or massage site. Monitor platelets.

Frequently Asked Questions

Common student questions on this topic.

Quick-Reference Cheatsheet

Every key point from this guide on a single printable page.