Fractures + Back Problems

Soft Tissue Injuries

• Usually result from trauma and include sprains, strains, dislocations, and subluxations.

• In younger patients, common sports-related injuries requiring ED care include sprains/strains, growth plate injuries, and repetitive motion injuries; these injuries have increased with greater sports and fitness participation.

Sprain

• Injury to the ligaments surrounding a joint, usually caused by a wrenching or twisting motion. Common sites include the ankle, wrist, and knee.

• First-degree involves a few torn fibers with mild tenderness/minimal swelling; second-degree is a partial ligament tear with increased swelling/tenderness; third-degree is a complete ligament tear with moderate to severe swelling.

• Common findings include pain, edema, bruising, and decreased function. Severe injury may cause an avulsion fracture, joint instability, subluxation/dislocation, or hemarthrosis.

Strain

• Excessive stretching or tearing of a muscle and its fascial sheath, often involving the tendon. Common sites include the lower back, calf, and hamstrings.

• First-degree is a mild or slightly pulled muscle; second-degree is a moderately torn muscle; third-degree is a severe tear or rupture. A defect may be visible or palpable with a major tear.

• Common findings include pain, edema, bruising, and decreased function, with pain worsening during continued use. Severe injuries may require surgical repair of the muscle, tendon, or fascia.

Dislocation

• Complete separation of the articular surfaces of a joint; subluxation is only a partial displacement. Common findings include obvious deformity, pain, tenderness, swelling, and loss of function.

• Requires prompt reduction because vascular injury can cause avascular necrosis or compartment syndrome; neurovascular assessment is critical. Closed reduction is preferred when possible, followed by immobilization and gradual rehabilitation.

• Common sites include the shoulder, elbow, thumb, hip, and patella. Anterior shoulder dislocations are most common; posterior shoulder dislocations are rare and are classically associated with seizures or electrocution.

Repetitive Strain Injury (RSI)

• Results from prolonged force, repetitive movements, or awkward postures that strain muscles, tendons, and ligaments, causing tiny tears and inflammation. Symptoms include pain, weakness, numbness, swelling, and impaired motor function.

• Risk increases with repetitive work/sports, poor posture, poor ergonomics, repetitive heavy lifting, and inadequate rest. Prevention focuses on proper ergonomics, positioning, and regular stretch breaks.

• Treatment is supportive and includes rest, heat or cold therapy, NSAIDs, and physical therapy for strength and conditioning.

Carpal Tunnel Syndrome (CTS)

• Caused by compression of the median nerve as it passes through the carpal tunnel at the wrist. Risk increases with repetitive wrist movement, pregnancy/menopause, diabetes, RA, PVD, trauma, or swelling.

• Causes pain, numbness, tingling, weakness, and decreased fine motor ability in the median nerve distribution; symptoms may worsen at night and improve by shaking the hand. Positive Tinel and Phalen signs support the diagnosis.

• Initial treatment includes activity modification, ergonomic changes, wrist splinting in a neutral position, PT, and possible corticosteroid injection. Persistent symptoms or significant EMG impairment may require carpal tunnel release surgery.

Rotator Cuff Injury

• Involves the supraspinatus, infraspinatus, teres minor, and subscapularis muscles; injury may result from aging, repetitive overhead motion, falls, heavy lifting, or direct trauma. Findings include shoulder weakness, decreased ROM, a painful arc with abduction from 60–120°, and a positive drop arm test; MRI can confirm a tear.

• Partial tears may be treated with rest, ice/heat, NSAIDs, corticosteroid injections, and PT. Complete tears or failed conservative treatment may require surgical repair; prolonged immobilization should be avoided because it can cause frozen shoulder.

Meniscus Injury

• Usually results from rotational stress with the knee flexed and foot planted, a direct blow, or degeneration. Findings include knee pain/tenderness, effusion, instability, and reports of clicking, popping, locking, or giving way; a positive McMurray test causes pain with knee movement.

• MRI can confirm the injury. Initial treatment includes ice, immobilization, crutches, and a knee brace, followed by PT for ROM and strength; persistent or severe injuries may require arthroscopic repair or meniscectomy.

Anterior Cruciate Ligament (ACL) Injury

• Commonly occurs as a noncontact injury during pivoting, landing from a jump, or abruptly stopping while running. Patients often report a twisting injury with a “pop,” followed by acute pain, swelling, instability, and inability to continue activity.

• A positive Lachman test suggests a tear, and MRI confirms the injury and associated damage. Treatment may include rest, ice, NSAIDs, elevation, crutches, bracing, and PT; severe injuries in active patients may require ACL reconstruction, with recovery often taking 6–8 months.

Bursitis

• Inflammation of a bursa caused by repeated trauma/friction, gout, RA, or infection. Common findings include warmth, pain, swelling, and limited ROM, often affecting the elbow, shoulder, knee, hand, or hip.

• Treatment focuses on correcting the cause and may include rest, immobilization, ice, NSAIDs, aspiration, or corticosteroid injection. Septic cases require antibiotics and often incision/drainage; chronic thickening may require bursectomy.

Open Fracture

• The skin is broken at the fracture site, exposing the injury to the external environment and causing associated soft-tissue damage.

• Usually results from severe trauma and carries an increased risk for contamination and infection.

Closed Fracture

• The bone is broken, but the skin remains intact over the fracture site.

• There is no communication between the fracture and the external environment.

Complete Fracture

• The break extends completely through the bone, separating it into two or more fragments.

Incomplete Fracture

• The break extends only partly through the bone, so some continuity of the bone remains.

• Often results from bending or crushing forces; a greenstick fracture is a type of incomplete fracture.

Displaced Fracture

• The broken bone ends are separated and no longer in their normal anatomic alignment.

• Often associated with comminuted or oblique fracture patterns and may require reduction to restore alignment.

Nondisplaced Fracture

• The bone is broken, but the fragments remain in normal alignment.

• Transverse, spiral, and greenstick fractures may be nondisplaced.

Transverse Fracture

• The fracture line extends straight across the bone shaft at a right angle to the bone's longitudinal axis.

Linear Fracture

• The fracture line runs parallel to the long axis of the bone rather than across it.

Oblique Fracture

• The fracture line extends diagonally across and down the bone.

• This pattern may be displaced because the angled fragments can move out of alignment.

Spiral Fracture

• The fracture line twists or spirals around the bone shaft, typically resulting from a twisting force.

• The fracture may have a corkscrew-like appearance.

Greenstick Fracture

• An incomplete break in which one side of the bone splinters or cracks while the opposite side bends.

• Occurs most often in children because their bones are more flexible.

Comminuted Fracture

• The bone is broken into more than two fragments, with smaller fragments sometimes appearing to “float.”

• Often results from significant trauma and is commonly associated with displacement.

Fracture Manifestations

• Common findings include immediate pain, decreased function, and inability to bear weight or use the affected extremity.

• The patient often guards and protects the injured area from movement, and obvious deformity may be present.

Fracture Healing: Fracture Hematoma

• Bleeding at the fracture site forms a hematoma around the ends of the bone fragments. The blood changes from a liquid to a semisolid clot within the first 72 hours after injury.

Fracture Healing: Granulation Tissue

• The hematoma is converted into granulation tissue as phagocytosis removes necrotic tissue. New blood vessels, fibroblasts, and osteoblasts form the basis for new bone tissue.

• Usually occurs about days 3–14 after the fracture.

Fracture Healing: Callus Formation

• Calcium, phosphorus, magnesium, and new bone matrix are deposited, forming an unorganized network of bone around the fracture.

• The callus contains cartilage, osteoblasts, calcium, and phosphorus and usually appears by the end of the second week; it can be seen on x-ray.

Fracture Healing: Ossification

• The callus becomes ossified and strong enough to prevent movement at the fracture site with gentle stress, although the fracture line may still be visible on x-ray.

• Occurs from about 3 weeks to 6 months. Limited mobility may be allowed and the cast may sometimes be removed during this stage.

Fracture Healing: Consolidation

• Continued callus development and ossification close the gap between bone fragments until complete bony union occurs.

• Represents radiologic union, when x-ray shows complete healing, and may take up to 1 year after injury.

Fracture Healing: Remodeling

• Excess bone is resorbed and the bone gradually returns toward its preinjury shape and strength. New bone forms where stress is applied and is resorbed where little stress occurs.

• Weight bearing and exercise are gradually introduced because physical loading helps guide the remodeling process.

Fracture Healing Complication: Angulation

• The healed bone forms at an abnormal angle because the fracture fragments were not maintained in proper alignment.

Fracture Healing Complication: Delayed Union

• Healing occurs more slowly than expected, but the fracture eventually unites.

Fracture Healing Complication: Malunion

• The fracture heals, but the bone fragments unite in an incorrect position or alignment, which may cause deformity or impaired function.

Fracture Healing Complication: Myositis Ossificans

• Abnormal bone forms within muscle or other soft tissue after trauma, causing pain, swelling, stiffness, and decreased ROM.

Fracture Healing Complication: Nonunion

• The fracture fails to heal and the bone ends do not unite.

Fracture Healing Complication: Pseudoarthrosis

• A persistent nonunion develops a false joint between the unhealed bone ends, allowing abnormal movement at the fracture site.

Fracture Healing Complication: Refracture

• The bone breaks again at or near the original fracture site, often before full strength has returned.

Goals of Fracture Treatment

• Restore anatomic alignment of the bone fragments through reduction, then maintain that alignment with immobilization.

• Restore normal or near-normal function of the injured extremity or body part.

• For open fractures, preventing infection is an additional major priority.

Fracture Reduction: Closed Reduction

• Nonsurgical manual realignment of bone fragments to restore normal position, length, and alignment. Traction and countertraction are applied, usually under local or general anesthesia.

• After reduction, a cast, splint, brace, or traction may be used to maintain alignment and immobilize the fracture while healing occurs.

Fracture Reduction: Open Reduction

• Surgical correction of bone alignment, usually with internal fixation using wires, screws, pins, plates, rods, or nails.

• Major risks include infection, anesthesia complications, and problems related to existing conditions such as diabetes.

• ORIF allows earlier ambulation, which helps decrease complications associated with prolonged immobility.

Fracture Reduction: Traction

• Applies a pulling force to align or reduce fractures/dislocations, decrease pain and muscle spasms, and immobilize the injured area. Countertraction pulls in the opposite direction.

• Skin traction is usually short term, about 48–72 hours; assess the skin and pressure points every 2–4 hours. Skeletal traction uses pins or wires inserted into bone for longer-term alignment and has a major risk of pin-site infection.

• Traction must remain continuous. Keep weights hanging freely and off the floor, maintain proper body alignment, and never remove or add weights unless prescribed.

Fracture Immobilization: Cast

• A temporary immobilization device often applied after closed reduction; it usually immobilizes the joints above and below the fracture to maintain alignment and promote healing.

• Fiberglass casts are most common because they are lighter, relatively waterproof, longer lasting, and allow earlier weight bearing than plaster casts.

• Fresh plaster casts should remain uncovered, be handled with open palms, and not bear weight until fully hardened, usually about 36–72 hours.

Fracture Immobilization: External Fixation

• Uses metal pins or wires inserted into bone and connected to external rods to stabilize and align fracture fragments.

• Commonly used for complex fractures with extensive soft-tissue damage, nonunion, malunion, limb lengthening, or when casting/traction is not appropriate.

• Monitor for pin loosening and infection; meticulous pin-site care is essential because infection may require removal of the device.

Fracture Immobilization: Internal Fixation

• Uses surgically implanted pins, plates, intramedullary rods, or screws to realign and maintain bone fragments.

• Provides stable fixation and is commonly used with open reduction.

• Bone alignment and healing are monitored regularly with x-rays.

Cast: Upper Extremity Injuries

• May be immobilized with a sugar-tong splint, posterior splint, short arm cast, or long arm cast. Sugar-tong splints are useful for acute wrist injuries or injuries with significant swelling.

• Short arm casts are commonly used for stable wrist or metacarpal fractures, while long arm casts are used for stable forearm, elbow, or unstable wrist fractures.

• Elevate the extremity with a sling to reduce edema unless a hanging arm cast is being used. Encourage finger movement and movement of any joints that are not immobilized.

Cast: Vertebral Injuries

• Stable thoracic or lumbar spine injuries may be supported with a body jacket brace that extends around the chest and abdomen.

• Monitor respiratory status, bowel and bladder function, and pressure areas over bony prominences.

• Watch for cast syndrome from compression of the duodenum, causing abdominal pain/pressure, nausea, vomiting, and decreased bowel sounds; treatment may require NG decompression and brace adjustment/removal.

Cast: Lower Extremity Injuries

• May be immobilized with a long leg cast, short leg cast, cylinder cast, splint, or immobilizer depending on the injury.

• Elevate the extremity above heart level for the first 24 hours and avoid prolonged dependent positioning because it increases edema.

• Monitor closely for compartment syndrome and pressure areas, especially increasing pain or burning at the heel, anterior tibia, fibular head, and malleoli.

Electrical Bone Growth Stimulation

• Promotes healing by stimulating formation of new bone, cartilage, and blood vessels and is especially useful for delayed union or nonunion fractures.

• Noninvasive methods use direct current or pulsed electromagnetic fields through electrodes placed over the skin or cast, often worn 10–12 hours per day.

• Semi-invasive methods place electrodes through the skin into bone, while invasive methods require surgical implantation of a current generator and electrode.

Fracture Drug Therapy

• Muscle relaxants such as carisoprodol, cyclobenzaprine, or methocarbamol may be used to relieve pain caused by muscle spasms.

• For an open fracture with unknown immunization status, tetanus and diphtheria toxoid or tetanus immunoglobulin may be given.

• Bone-penetrating antibiotics are used prophylactically before surgery; a common example is the cephalosporin cefazolin.

Fracture Nutrition Therapy

• Adequate nutrition supports soft-tissue and bone healing; include about 1 g/kg/day of protein plus vitamins B, C, and D, calcium, potassium, phosphorus, and magnesium.

• Encourage 2000–3000 mL of fluid daily and a high-fiber diet with fruits and vegetables to help prevent constipation.

• If immobilized in skeletal traction or a body jacket brace, eat 6 small meals per day to reduce abdominal pressure and cramping.

Fracture Nursing Assessment

• Obtain the mechanism of injury, position found, relevant health history, medications, and symptoms such as pain, numbness, tingling, weakness, or loss of function.

• Assess for deformity, edema, bruising, crepitus, muscle spasm, wounds, exposed bone, shortening/rotation, and inability to use the affected part. Treat life-threatening problems first.

• If a fracture is suspected, immobilize the extremity in the position found and splint the joints above and below the injury. Do not straighten the extremity or manipulate protruding bone.

Fracture Neurovascular Assessment

• Assess distal to the injury before and after splinting/casting, and compare both extremities. Check color, temperature, capillary refill, pulses, edema, sensation, motor function, and pain.

• Pallor, coolness, delayed capillary refill, or decreased/absent pulses may indicate arterial insufficiency; a warm cyanotic extremity may indicate poor venous return. Paresthesia or increasing pain may signal neurovascular compromise.

• Upper extremity motor checks include finger abduction (ulnar), thumb-to-small-finger opposition (median), and wrist/finger extension (radial). Lower extremity checks include dorsiflexion (peroneal) and plantar flexion (tibial); teach the patient to immediately report new numbness, tingling, or inability to move digits.

Goals of Patient with a Fracture

• Promote fracture healing without complications.

• Provide acceptable pain relief.

• Help the patient achieve maximal rehabilitation and return of function.

Fracture Implementation: Acute Care

• If surgery is required, provide routine preoperative care and teach about expected immobilization, assistive devices, activity restrictions, and pain-management strategies.

• After surgery, monitor vital signs and perform frequent neurovascular assessments. Maintain proper alignment and positioning, follow movement restrictions, and monitor casts, dressings, and drains for increasing, bloody, or purulent drainage.

• Prevent complications of immobility by encouraging activity and ROM as allowed, maintaining fluids around 2500 mL/day unless contraindicated, providing a high-fiber diet, and monitoring for constipation, renal stones, orthostatic hypotension, VTE, and decreased lung function.

Fracture Implementation: Traction

• Inspect exposed skin and pressure areas frequently because prolonged pressure can cause skin necrosis and impair nerves or blood vessels. Assess skeletal traction or external fixation pin sites for infection and provide prescribed pin-site care.

• For an unrepaired hip fracture, external rotation is expected; if traction is ordered, apply it without trying to realign the extremity. Keep the patient centered and supine to maintain countertraction.

• Encourage allowed ROM, position changes, deep breathing, and isometric exercises several times daily. A trapeze may be used, if permitted, to help with repositioning and care.

Fracture Implementation: Ambulatory Care

• Cast care: Perform frequent neurovascular checks. Elevate the extremity above heart level and use ice initially for edema, but do not elevate above the heart if compartment syndrome is suspected. Teach the patient not to insert objects into the cast and to report tightness, pressure, or increasing discomfort.

• Ambulation: Know the prescribed weight-bearing status: non–weight-bearing, toe-touch, partial weight-bearing, weight bearing as tolerated, or full weight-bearing. Coordinate analgesia before PT and reinforce safe mobility techniques.

• Assistive devices: Canes are held on the side opposite the injured extremity. The device and injured limb generally advance together, followed by the unaffected limb; avoid bearing weight on the axilla when using crutches because this can damage the neurovascular bundle.

• Psychosocial concerns: Promote gradual return to independence with ADLs, strength, and endurance. Assess for effects such as financial stress, disability concerns, separation from family, and posttraumatic stress disorder after serious injury.

Fracture Complications: Direct

• Occur at or near the fracture site and include infection, problems with bone union, and avascular necrosis.

• Open fractures have a higher risk for infection because the fracture communicates with the external environment.

Fracture Complications: Indirect

• Result from systemic effects of the fracture or immobility and include compartment syndrome, VTE, fat embolism syndrome, rhabdomyolysis, and hypovolemic shock.

• These complications can become life-threatening and require rapid recognition and treatment.

Fracture Complications: Infection

• Open fractures have a high risk for infection because the fracture communicates with the outside environment, allowing contamination by microorganisms or foreign material. Damaged tissue and blood vessels also weaken local defenses.

• Prevention focuses on surgical irrigation and debridement to remove contaminants and devitalized tissue. Antibiotic solution or antibiotic-impregnated beads may also be used.

• IV antibiotics are commonly given for at least 3 days. Severe soft-tissue damage may require repeat debridement, drainage, or skin grafting.

Fracture Complications: Compartment Syndrome

• Increased pressure within a closed muscle compartment compresses blood vessels and nerves, reducing tissue perfusion and causing ischemia. It most often affects the leg but can occur in any muscle group.

• Causes include decreased compartment size from tight casts, dressings, splints, excessive traction, or fascia closure, and increased contents from bleeding, edema, inflammation, or IV infiltration.

• Commonly follows long-bone fractures, crush injuries, or major soft-tissue trauma. Untreated ischemia can cause permanent nerve and muscle damage, contractures, disability, and loss of function.

Compartment Syndrome: Clinical Manifestations

• The 6 Ps are pain, pressure, paresthesia, pallor, paralysis, and pulselessness.

• Pain is typically out of proportion to the injury, poorly relieved by opioids, and worsened by passive stretching of the affected muscles.

• Ischemia may occur within 4–8 hours; paralysis and pulselessness are late findings that suggest severe neurovascular compromise.

Compartment Syndrome: Interprofessional Care

• Perform frequent neurovascular assessments and report early signs immediately, especially pain out of proportion to the injury that is not relieved by analgesics and new paresthesia. Do not wait for pulselessness or paralysis because these are late signs.

• Relieve external pressure as ordered by bivalving the cast, loosening dressings, or reducing traction weight. Do not elevate the extremity above heart level and do not apply cold because vasoconstriction can worsen ischemia.

• Severe cases may require an emergency fasciotomy to decompress the compartment; the incision is often left open for several days. Prolonged ischemia may lead to amputation.

Hip Fracture

• Usually affects the proximal third of the femur and is especially common in older adults; about 95% result from falls. Risk is increased by osteoporosis/osteopenia, impaired balance or gait, vision/hearing changes, slowed reflexes, orthostatic hypotension, and medication use.

• Intracapsular fractures occur within the joint capsule and include capital, subcapital, and transcervical/femoral neck fractures. These are often fragility fractures associated with osteoporosis and minor trauma.

• Extracapsular fractures occur outside the joint capsule and include intertrochanteric and subtrochanteric fractures; they are commonly caused by falls or more severe direct trauma.

Hip Fracture: Clinical Manifestations

• Common findings include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness around the fracture site.

• A displaced femoral neck fracture can disrupt blood flow to the femoral head, increasing the risk for avascular necrosis.

Hip Fracture: Interprofessional Care

• Immediate surgery is the standard of care because early repair allows earlier mobilization and decreases complications from immobility.

• Buck’s traction may be used for about 24–48 hours before surgery if the patient first needs stabilization; it helps reduce painful muscle spasms.

• Surgical options include closed reduction with percutaneous pinning, internal fixation, hemiarthroplasty for some femoral neck fractures, or total hip replacement involving both the femur and acetabulum.

Hip Fracture Nursing Management: Preoperative Care

• Assess and stabilize chronic conditions such as diabetes or heart disease before surgery if needed. Begin discharge planning early because hospitalization after surgery is usually only a few days.

• Manage severe pain and muscle spasms with analgesics, muscle relaxants, comfortable positioning, and properly applied traction if ordered.

• Provide routine preoperative teaching about the procedure, expected mobility limits, and postoperative care as time allows.

Hip Fracture Nursing Management: Postoperative Care

• Monitor vital signs, intake/output, respiratory status, pain, incision/dressing, and frequent neurovascular status of the affected extremity. Elevate the leg to reduce edema and maintain proper alignment.

• Early mobility is important; patients are often out of bed on the first postoperative day. Follow prescribed weight-bearing restrictions, coordinate with PT, and ensure safe use of a walker or crutches.

• After a posterior hip replacement, prevent dislocation by avoiding hip flexion greater than 90°, adduction/crossing the legs, and internal rotation. Sudden severe pain, shortening, external rotation, or a buttock lump may indicate dislocation; keep the patient NPO and notify the HCP.

Hip Fracture Nursing Management: Ambulatory Care

• Continue monitoring pain, infection, and VTE risk after discharge. Teach anticoagulant safety and required monitoring if anticoagulation is prescribed.

• Continue strengthening and ROM exercises for the quadriceps and hip muscles for several months; avoid high-impact activities that may loosen the implant.

• Reduce fall risk by removing throw rugs and other hazards, improving lighting, adding grab bars and stair rails, and using calcium/vitamin D or osteoporosis therapy as prescribed.

Low Back Pain

• Most often results from a musculoskeletal problem and may be localized or diffuse. Localized pain is felt over a specific tender area, while diffuse pain is spread over a larger area and usually comes from deeper tissues.

• Radicular pain results from nerve-root irritation and radiates along a nerve distribution; sciatica is a common example. Referred pain is felt in the lower back even though the source is elsewhere, such as the kidneys or lower abdomen.

• Acute low back pain lasts 4 weeks or less and may follow yard work, sports injury, trauma, or a motor vehicle crash. The lumbar region is especially vulnerable because it bears most body weight, is highly flexible, contains nerve roots at risk for injury, and has poor biomechanical structure.

Low Back Pain: Risk Factors

• Poor muscle tone, excess body weight, poor posture, older age, smoking, pregnancy, prior spinal compression fracture, congenital spinal problems, and family history increase the chance of developing this problem.

• Repetitive heavy lifting, prolonged sitting, and frequent vibration exposure are common occupational contributors; healthcare workers are especially vulnerable because of lifting, transferring, and repositioning patients.

• Acute lumbosacral strain, lumbosacral instability, osteoarthritis, degenerative disc disease, and herniated intervertebral discs are common musculoskeletal causes associated with these complaints.

Acute Low Back Pain

• Lasts 4 weeks or less and is usually caused by trauma or activities that place excessive stress, often hyperflexion, on the lower back. Common triggers include heavy lifting, yard work, sports injuries, and sudden jolts such as motor vehicle crashes.

• Symptoms may be delayed and often develop within 24 hours as edema or disc-related pressure increases around a nerve. Findings range from muscle aching to shooting or stabbing pain, decreased flexibility/ROM, or inability to stand upright.

• The straight-leg-raising test may help assess nerve irritation. MRI or CT is generally reserved for suspected trauma or systemic disease such as cancer or spinal infection.

Acute Low Back Pain: Acute Care

• Mild to moderate episodes are usually treated as an outpatient with NSAIDs and muscle relaxants such as cyclobenzaprine. Massage, manipulation, acupuncture, and hot or cold compresses may help; severe pain may require a short course of corticosteroids or opioid analgesics.

• A brief 1–2 day period of rest may be used, but prolonged bed rest should be avoided. Most patients recover better by continuing normal activities while avoiding lifting, bending, twisting, prolonged sitting, or anything that worsens pain.

• Symptoms usually improve within about 2 weeks and often resolve without further treatment.

Acute Low Back Pain: Ambulatory Care

• Long-term care focuses on preventing repeat episodes through strengthening and stretching exercises, especially for the core and abdominal muscles, along with good posture and proper body mechanics.

• Maintain a healthy weight, stop smoking, use supportive low-heeled shoes, avoid sleeping prone, and use side-lying or supine positions with the hips and knees flexed. Use proper lifting technique by bending at the knees and keeping objects close to the body.

• Avoid prolonged standing or poor positioning, and use safe lifting or transfer equipment when handling patients. Physical therapy, occupational counseling, or a structured “Back School” program may be helpful for recurrent or work-related problems.

Chronic Low Back Pain

• Lasts longer than 3 months or involves repeated incapacitating episodes and is often progressive; the exact cause may be difficult to identify.

• Common causes include arthritis or degenerative disc disease, osteoporosis or other metabolic bone disease, scar tissue from prior injury, chronic strain from obesity, pregnancy, or poor occupational posture, and congenital spinal problems.

Spinal Stenosis

• Narrowing of the spinal canal or space around the nerve roots causes compression and inflammation, leading to low back pain, weakness, numbness, or tingling. It may be acquired from OA, RA, tumors, Paget disease, or trauma, or inherited with conditions such as congenital stenosis or scoliosis.

• Lumbar pain often radiates to the buttocks and legs and worsens with walking or prolonged standing. Relief with sitting or bending forward is characteristic, and patients may also report leg heaviness, weakness, or numbness.

Chronic Low Back Pain: Interprofessional and Nursing Care

• Treatment is similar to acute low back pain and focuses on reducing pain and stiffness while maintaining mobility. NSAIDs may be used for daily discomfort, duloxetine may help pain and sleep, and gabapentin may improve leg symptoms and walking.

• Weight reduction, regular exercise/activity, rest periods, local heat, and physical therapy can reduce pain, improve posture, and keep muscles and joints mobile. Acupuncture, yoga, or biofeedback may also help some patients.

• Persistent symptoms may require epidural corticosteroid injections or implanted pain-delivery devices. Surgery may be considered for severe pain that does not improve with conservative treatment or for continued neurologic deficits.

Degenerative Disc Disease (DDD)

• Results from age-related loss of fluid in the intervertebral discs, causing them to lose elasticity, flexibility, and shock-absorbing ability. This degeneration is considered a normal aging process unless it causes pain.

• The nucleus pulposus dries and shrinks, making the disc thinner and less able to distribute pressure between vertebrae. More stress is transferred to the annulus fibrosus, causing progressive wear and damage.

• May occur with osteoarthritis of the spine as increased stress and poor joint lubrication contribute to cartilage damage and bone spur formation.

Herniated Disc (Slipped Disc)

• Occurs when the nucleus pulposus pushes or seeps through a torn or stretched annulus fibrosus, causing the disc to bulge outward between vertebrae.

• May result from aging, repeated stress, trauma, or spinal stenosis. The most common sites are L4–L5 and L5–S1; cervical herniation commonly occurs at C5–C6 and C6–C7.

• Compression of a spinal nerve can cause radiculopathy, including radiating pain, numbness, tingling, weakness, and decreased ROM.

Intervertebral Disc Disease: Clinical Manifestations

• Lumbar involvement commonly causes low back pain with radicular pain that travels through the buttock and below the knee along the sciatic nerve. A positive straight-leg-raise may reproduce pain; paresthesia, leg weakness, and depressed or absent reflexes may also occur.

• Cervical involvement causes pain radiating into the arms and hands along the affected nerve distribution. Handgrip weakness may occur, and reflexes may be decreased or absent.

• Cauda equina syndrome from multiple lumbar nerve-root compression causes severe low back pain, progressive weakness, bowel or bladder retention/incontinence, and saddle anesthesia. It is a medical emergency requiring rapid surgical decompression to prevent permanent neurologic damage.

Intervertebral Disc Disease: Diagnostic Studies

• X-rays help identify structural abnormalities, while MRI, CT, or myelography can localize the damaged disc or area of nerve compression.

• If results are unclear, a diskogram or epidural venogram may be used. EMG of the extremities helps determine the severity of nerve irritation and can help rule out disorders such as peripheral neuropathy.

Intervertebral Disc Disease: Interprofessional Care

• Most suspected disc damage is treated conservatively with limited extreme spinal movement, braces or supports, heat or ice, ultrasound, massage, traction, TENS, and medications such as NSAIDs, short-term corticosteroids, opioids, muscle relaxants, antiseizure drugs, or antidepressants.

• Epidural corticosteroid injections may temporarily reduce inflammation and acute pain, but symptoms can recur if the underlying cause remains.

• Once symptoms improve, begin back-strengthening exercises about twice daily and continue long term. Use proper body mechanics and avoid excessive spinal flexion and twisting; most patients improve within about 6 months with conservative treatment.

Intervertebral Disc Disease: Surgical Therapy

• Surgery is considered when conservative treatment fails, radiculopathy worsens, constant pain or persistent neurologic deficits occur, or bowel/bladder control is lost. Loss of bowel or bladder function requires urgent evaluation for serious nerve compression.

• Minimally invasive options include IDET, radiofrequency discal nucleoplasty, interspinous devices, microdiscectomy, and percutaneous discectomy. Laminotomy with discectomy is the most common surgery and removes the herniated disc portion compressing the nerve root.

• Other options include artificial disc replacement to preserve motion and spinal fusion to stabilize an unstable spine; fusion may use bone grafts plus rods, plates, or screws.

Spine Surgery: Nursing Management

• Maintain proper spinal alignment and use logrolling for position changes. After lumbar fusion, place pillows under the thighs when supine and between the legs when side-lying; use braces or orthotics as ordered and advance activity according to restrictions.

• Perform frequent neurologic and neurovascular assessments and compare findings with the preoperative baseline. Report new weakness, paresthesia, bowel/bladder dysfunction, severe headache, uncontrolled pain, or worsening neurologic status immediately.

• Monitor for CSF leakage, which may appear as clear or slightly yellow drainage and may cause a severe headache; if suspected, place the patient flat. Also monitor pain, wound infection, bowel sounds/gas, constipation or ileus, urinary retention/incontinence, and teach proper body mechanics with no spinal twisting.