Orthopaedic Nursing Care
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Direct answer
The six Ps make compartment syndrome famous — pain, pallor, paraesthesia, pulselessness, paralysis, pressure — but the mark-winning fact is that pain out of proportion to the injury, and pain on passive stretch, arrive first while pulses are still present, because tissue perfusion fails long before the large arterial trunks occlude. Orthopaedic nursing spans trauma and elective work: fracture and cast care, traction, joint replacement with its dislocation and thrombosis precautions, spinal injury positioning, and amputation aftercare. Its recurring themes are neurovascular observation (the Ps checked hourly after injury or surgery), early mobilisation balanced against stability, DVT and pressure-ulcer prophylaxis in immobile patients, and early detection of fat embolism syndrome — respiratory distress with confusion and a petechial rash on chest, axillae and conjunctivae, classically 24 to 72 hours after long-bone fracture.
What you must remember
- Compartment syndrome: pain on passive stretch is the earliest and most reliable sign; tense compartment, paraesthesia, then the late pulselessness; pressures above about 30 mmHg (or within 30 of diastolic) suggest the diagnosis — treatment is emergency fasciotomy, and missing it produces Volkmann's ischaemic contracture.
- Fat embolism syndrome triad: respiratory compromise (tachypnoea, hypoxia), neurological changes (confusion, drowsiness) and petechial rash over chest, axillae and conjunctivae, typically 24 to 72 hours after long-bone or pelvic fracture — treat with oxygen and supportive care; early fixation prevents it.
- Neurovascular observation (the 6 Ps): pain, pallor, paraesthesia, paralysis, pulselessness, poikilothermia — charted hourly after reduction, cast application or vascular injury; a cast may need immediate splitting if the limb becomes ischaemic.
- Total hip replacement precautions (posterior approach): no hip flexion beyond 90 degrees, no adduction past midline, no internal rotation — use an abduction pillow between knees, high chair and raised toilet seat, typically for 6 to 12 weeks per surgeon protocol.
- DVT prophylaxis: early mobilisation, ankle-pump exercises, compression stockings or pneumatic compression, and pharmacological prophylaxis (low molecular weight heparin) per prescription — watch for calf pain and swelling.
- Crutch walking (gaits): four-point (slowest, most stable, weight on both legs), two-point (faster), three-point (one limb non-weight-bearing), swing-to and swing-through; crutch pads sit 2 to 3 finger-breadths below the axilla — weight on the hands, never the axillae (radial nerve crutch palsy).
- Amputation care: figure-of-eight stump wrapping, shrinker socks, skin inspection, desensitisation by tapping and massage, and distinguishing phantom limb sensation (normal, fades) from phantom pain (needs treatment).
- Infection watch: post-operative fever with wound redness or drainage in a prosthetic joint is an emergency — prosthetic infection risks revision or removal.
A night on the trauma ward
A 24-year-old with a plated tibial fracture, six hours post-operative, rings the bell: analgesia is "not touching" the pain. The nurse evaluates the 6 Ps, finds a tense, swollen calf compartment with exquisite pain on passive toe extension and tingling in the first web space — pulses present, leg pink. She does not wait for pallor: leg elevated no higher than the heart, limb split (cast and dressing down to skin if needed), analgesia escalated, surgeon called, compartment pressures documented en route to theatre for fasciotomy. Two beds away, a day-two femoral fracture develops tachypnoea with falling saturation and confusion; the nurse notes petechiae over the chest wall and conjunctiva, starts oxygen, positions semi-Fowler's, and escalates — the fat embolism window is 24 to 72 hours and this is hour 40. The joint-replacement patient next door is turned with an abduction pillow, does ankle pumps, receives her LMWH and stands within the surgeon's protocol.
Where orthopaedic exams hunt for marks
Examiners deliberately test the pulse trap in compartment syndrome: candidates who wait for a pulseless limb will fail a patient — the expected answer is pain on passive stretch with a tense compartment while pulses are still present. The second favourite is the timing of fat embolism (24 to 72 hours, long bones, petechial distribution) and its prevention by early fixation. Indian viva staples include the three hip precautions after posterior-approach replacement (no flexion beyond 90, no adduction, no internal rotation), crutch-height placement, and the figure-of-eight stump bandage. Road traffic injuries make polytrauma nursing a national priority in India, and geriatric hip-fracture pathways emphasise time-to-surgery, delirium screening and early mobilisation — "surgery within 48 hours for neck-of-femur fractures where feasible" shows guideline awareness.
Frequently asked questions
What is the earliest reliable sign of compartment syndrome?
Pain out of proportion to the injury, with severe pain on passive stretch of the compartment's muscles, occurring while distal pulses are still present — requiring immediate fasciotomy when confirmed.
When does fat embolism syndrome typically appear and how?
At 24 to 72 hours after long-bone or pelvic fractures: respiratory distress, neurological changes and petechial rash on chest, axillae and conjunctivae.
Which precautions follow posterior-approach total hip replacement?
Avoid hip flexion beyond 90 degrees, adduction past midline and internal rotation for the surgeon-defined period (commonly 6 to 12 weeks), using an abduction pillow and raised seating.
How is weight correctly borne on crutches?
On the hands through the hand grips with the crutch tops held 2 to 3 finger-breadths below the axillae — axillary pressure causes crutch (radial nerve) palsy.
How are phantom limb sensation and phantom pain managed differently?
Sensation without pain is normal and usually fades with desensitisation; phantom pain needs multimodal treatment — medication, mirror therapy, TENS — and persistent pain warrants referral.