Musculoskeletal injury and surgery

Ortho emergencies are mechanical: a cast that strangulates, fat that embolizes after a long bone breaks, and a new hip that dislocates if the client bends past the rules.

Fracture complications

After a fracture or cast, the two emergencies that rewrite the priority list are rising pressure inside a muscle compartment and fat traveling from marrow into the lungs and brain. Both look like “give more pain meds” or “wait and reassess” until you name the mechanism.

Compartment syndrome is ischemia from pressure that outruns arterial inflow inside a closed fascial space. Pain out of proportion and pain that spikes with passive stretch are early cues because muscle is already starving. Tight swelling and paresthesia follow; pallor and lost pulses are late. Elevate the limb to heart level as ordered for comfort and venous return, but do not treat “raise it high above the heart” as the fix. That can worsen arterial perfusion. Notify, loosen constricting wraps if protocol allows, and move toward fasciotomy evaluation.

Fat embolism usually follows long-bone fracture or repair when marrow fat enters circulation. Sudden confusion, hypoxia, and a petechial rash (often chest, axilla, or conjunctiva) are the classic cluster. Support oxygenation and escalate; this is not a routine postop “calm the client” moment. The distractor that looks reasonable is chalking unrelieved cast pain up to underdosing alone, or treating new confusion after a femur repair as hospital anxiety while SpO2 is falling.

Surgery and precautions

After posterior total hip arthroplasty, the new joint can dislocate if the client flexes past about 90°, adducts past midline, or internally rotates as forbidden in the teaching. Precautions exist to keep the femoral head seated while soft tissue heals. Approach-specific rules vary; when the stem says posterior or gives the classic trio, enforce those three limits.

• Posterior approach THA: abduction pillow as ordered; high toilet seat; no bending to tie shoes the forbidden way.
• Watch for dislocation: sudden pain, limb shortening/rotation — do not force ROM.

An abduction pillow and raised toilet seat are not comfort props. They block adduction and deep flexion during sleep, transfers, and toileting. Tying shoes by bending at the hip, crossing legs, or pivoting on the operative leg are the everyday moves that break the rule set. Teach reachers, sock aids, and sitting strategies that keep the hip in the safe zone.

If the client reports sudden sharp pain with a shortened or rotated limb, stop ROM and escalate for possible dislocation. Forcing the joint back into place is not a nursing maneuver. The distractor that looks helpful is letting the client “just bend once” to pick something up, or removing the abductor pillow because it is uncomfortable. Edge case: anterior-approach precautions differ; follow the stem’s approach and the ordered teaching rather than applying posterior rules to every THA.

Immobilization devices

1. Inspect skin/pin sites per protocol.
2. Keep weights hanging free and ropes unobstructed.
3. Neurovascular checks distal to cast/traction.
4. Do not remove weights to help the client “scoot up” without an order.

Gout flares still appear in this topic cluster: rest the joint, meds as ordered, hydrate, and limit high-purine triggers taught for that client.

Priority map