Neurovascular assessment as the default first action
Almost every musculoskeletal injury, cast, splint or surgical procedure creates a risk of compromised circulation or nerve function distal to the site. That is why neurovascular assessment is the reflex first action in this content area, and why so many correct answers begin with checking the extremity rather than administering something.
Assess and document six elements: pain, pallor or colour change, pulses, paraesthesia, paralysis or reduced movement, and temperature of the limb. Always compare with the opposite side, because a baseline difference can otherwise be misread as deterioration. Capillary refill under three seconds and warm, pink skin with intact sensation and movement describe an intact limb.
Changes are graded by urgency. Numbness and tingling are early nerve warnings. Coolness and pallor suggest reduced arterial flow. Loss of pulse and paralysis are late findings, meaning irreversible damage may already have begun. A common exam error is choosing to reassess in an hour when the correct answer is to report a new finding now.
- •Always compare with the unaffected limb
- •Numbness and tingling are early warnings, not minor complaints
- •Pulselessness and paralysis are late — do not wait for them
- •Document findings objectively with side-to-side comparison
Compartment syndrome and fat embolism
Compartment syndrome occurs when swelling or external constriction raises pressure within a fascial compartment until perfusion fails. The earliest and most reliable clue is pain that is out of proportion to the injury, unrelieved by opioids and dramatically worse when the muscles in the compartment are passively stretched. Tightness of the compartment and paraesthesia follow.
Nursing actions are specific and counterintuitive. Loosen or split constricting dressings and bivalve a cast if that is within your protocol, keep the limb at heart level rather than elevated, avoid applying ice, and notify the provider immediately. Elevation and cold both reduce arterial inflow and therefore worsen ischaemia in an already compromised compartment. Definitive treatment is fasciotomy.
Fat embolism syndrome typically follows long bone or pelvic fracture within twenty-four to seventy-two hours. Suspect it when a client develops sudden dyspnoea, hypoxaemia, tachycardia, confusion or restlessness, and a petechial rash across the chest, axillae or conjunctivae. Management is supportive with oxygen and immediate escalation; prevention relies on early fracture immobilisation.
| Complication | Timing | Distinguishing clue |
|---|---|---|
| Compartment syndrome | Hours after injury or casting | Pain worse on passive stretch, unrelieved by opioids |
| Fat embolism | 24–72 hours after long bone fracture | Dyspnoea, confusion and petechial rash |
| Venous thromboembolism | Days after immobility or surgery | Unilateral calf swelling, warmth, pain |
| Osteomyelitis | Days to weeks | Localised pain, fever, drainage at pin or wound site |
| Hip prosthesis dislocation | Any time after surgery | Shortened, internally rotated limb with acute pain |
Casts, traction and pin site care
A new plaster cast requires handling with the palms rather than fingertips to avoid indentations that create pressure points, and it must be left uncovered to air dry. Teach the client never to insert objects inside the cast to scratch, to keep it dry, and to report increasing pain, numbness, a burning sensation, foul odour, drainage or a hot spot, which may indicate pressure injury or infection beneath the cast.
Traction principles are heavily tested and simple. Weights hang freely and never rest on the floor or the bed frame. The nurse does not remove or lift the weights unless prescribed for skeletal traction. Ropes must sit in the pulley grooves, alignment must be maintained, and counter-traction is preserved by the client's body position rather than by pulling them up in bed.
Skeletal pin sites are cleaned according to protocol, usually with sterile technique. Clear drainage in small amounts can be normal early; purulent drainage, increasing redness, pin loosening, foul odour or fever suggest infection and are reported. Monitor for signs of osteomyelitis in any client with hardware and persistent localised pain.
Joint replacement precautions and rehabilitation
After a posterior approach total hip replacement, the prosthesis dislocates most easily with hip flexion beyond ninety degrees, adduction past midline and internal rotation. Teach the client to use an abduction pillow when in bed, avoid low chairs and low toilet seats, avoid crossing the legs, use a raised toilet seat and reacher, and avoid bending forward to reach the feet.
Signs of dislocation include sudden severe pain, a sensation of the hip popping, a limb that appears shortened and internally rotated, and inability to move the leg. This is reported immediately and the client is kept still. Anterior approach precautions differ, restricting extension and external rotation, and the exam usually specifies the approach when precision matters.
After total knee replacement, the focus is early mobility, achieving full extension and progressive flexion, and using the continuous passive motion device if prescribed. Across both procedures, venous thromboembolism prophylaxis, pain control adequate to permit physiotherapy, and infection surveillance form the recurring nursing plan.
- •Posterior hip: no flexion over 90 degrees, no adduction, no internal rotation
- •Use abduction pillow, raised toilet seat, reacher and long-handled shoehorn
- •Shortened, internally rotated limb with severe pain suggests dislocation
- •Knee replacement: prioritise full extension and early ambulation