Part 2 Complications of Fractures • Hip Fractures • Hip Replacement • Amputation

What are the five major complications of fractures?

Compartment syndrome, osteomyelitis, deep vein thrombosis (DVT), pulmonary embolism (PE), and fat embolism syndrome (FES).

What is compartment syndrome?

Increased pressure within a closed muscle compartment that compresses blood vessels, nerves, tendons, and muscles, causing ischemia.

What causes compartment syndrome?

Edema or bleeding within a closed muscle compartment.

What is the biggest danger of compartment syndrome?

Tissue ischemia leading to permanent muscle and nerve damage if untreated.

What complication can develop from untreated compartment syndrome?

Volkmann's contracture.

What are the earliest signs of compartment syndrome?

Pain out of proportion to the injury, pain with passive stretch, tense swollen compartment, paresthesia, decreased sensation.

What are the late signs of compartment syndrome?

Pulselessness, paralysis, pallor, cool extremity, necrosis, permanent nerve damage.

What assessment finding is the earliest indicator of compartment syndrome?

Pain out of proportion to the injury.

How is compartment pressure measured?

Using a wick catheter or handheld pressure monitoring device.

What is the priority nursing action when compartment syndrome is suspected?

Notify the provider immediately.

What should NEVER be done when compartment syndrome is suspected?

Do not elevate above heart level and do not apply ice.

What restrictive devices should be addressed in compartment syndrome?

Tight casts or dressings should be loosened or removed per protocol/provider.

What is the definitive treatment for compartment syndrome?

Emergency fasciotomy.

What is the purpose of a fasciotomy?

Surgically relieve pressure and restore tissue perfusion.

What improvements are expected after a successful fasciotomy?

Decreased pain, improved perfusion, improved sensation, improved movement.

After a fasciotomy, what nursing care is required?

Frequent neurovascular assessments, wound care, monitor for bleeding/infection, wound VAC or wet-to-dry dressings, adequate nutrition.

Why should severe pain in a patient with a cast never be ignored?

It may indicate impaired tissue perfusion or compartment syndrome.

How is fracture pain different from compartment syndrome pain?

Fracture pain usually improves with immobilization; compartment syndrome pain is severe and unrelieved.

How does edema pain typically respond?

It often improves with elevation and cold packs.

What type of pain may indicate a pressure ulcer beneath a cast?

Burning pain over a bony prominence.

What is osteomyelitis?

A severe infection of bone, bone marrow, and surrounding tissue.

What commonly causes osteomyelitis?

Open fractures, surgery, infected orthopedic hardware, IV drug use, diabetic wounds, vascular compromise.

What are common signs and symptoms of osteomyelitis?

Fever, chills, night sweats, elevated WBC count.

How is osteomyelitis diagnosed?

Imaging, blood cultures, and surgical or wound cultures.

What is the treatment for osteomyelitis?

Long-course IV antibiotics and surgical irrigation/debridement if needed.

What important nursing intervention occurs before antibiotics are started?

Obtain cultures if ordered.

What should nurses monitor closely with external fixation to prevent osteomyelitis?

Pin sites.

What NCLEX reminder helps remember osteomyelitis?

"You can't see it" because the infection is inside the bone.

What patients are at highest risk for DVT after fractures?

Patients with long-bone, pelvic, spine, or lower-extremity fractures and immobility.

What are signs of DVT?

Unilateral redness, warmth, pain, and edema.

How is DVT diagnosed?

Venous duplex ultrasound.

How is DVT prevented?

Early ambulation, anticoagulants, SCDs, compression stockings, hydration, leg exercises.

What should NEVER be done if DVT is suspected?

Massage the calf.

What is a pulmonary embolism?

A sudden blockage of a pulmonary artery.

What are signs of PE?

Sudden dyspnea, chest pain, tachycardia, low oxygen saturation, anxiety, pallor, altered mental status.

What is the nursing priority for a suspected PE?

ABCs and activate rapid response if needed.

How is PE treated?

Anticoagulation.

What is fat embolism syndrome (FES)?

A potentially fatal complication caused by fat entering the bloodstream after long-bone or pelvic fractures.

When does fat embolism syndrome usually occur?

12–72 hours after injury.

Which fractures most commonly cause fat embolism syndrome?

Long-bone and pelvic fractures.

What is the classic triad of fat embolism syndrome?

Respiratory distress, neurologic changes, petechial rash.

What respiratory findings occur with FES?

Hypoxemia and respiratory distress.

What neurologic findings occur with FES?

Confusion and altered mental status.

Where does the petechial rash appear in fat embolism syndrome?

Neck, upper chest, mouth, and eyes.

What laboratory findings occur with fat embolism syndrome?

Low calcium, low platelets, low serum lipids, elevated ESR.

How is fat embolism syndrome prevented?

Early fracture immobilization, minimal manipulation, maintain fluids/electrolytes.

What is the priority treatment for fat embolism syndrome?

Oxygen administration.

What positioning is recommended for FES?

High Fowler's if tolerated.

What additional treatments may be anticipated with severe FES?

ABGs, chest imaging, ICU care, ventilatory support, steroids, vasoactive medications, fluids, morphine.

What findings are commonly seen with a hip fracture?

Hip or groin pain, inability to bear weight, shortened leg, external rotation.

What are priority nursing interventions for a hip fracture?

Pain control, neurovascular assessment, immobilization, prevent pressure injuries and complications.

What is the primary treatment for most hip fractures?

Surgical repair or hip arthroplasty.

What is a total hip replacement (THR)?

Replacement of the damaged hip joint with a prosthesis.

What complications are common after hip fracture surgery?

DVT, PE, hemorrhage, pressure ulcers, pneumonia, neurovascular dysfunction, delirium, prosthesis dislocation.

What is the overall nursing priority after hip surgery?

Early ambulation.

Who has the greatest risk for hip prosthesis dislocation?

Patients with total hip arthroplasty.

How long are hip precautions generally maintained?

Approximately six weeks.

What are hip precautions?

Keep legs abducted, do not cross legs, avoid adduction, avoid hip flexion greater than 90 degrees, avoid internal rotation.

What should be placed between the patient's legs when turning after hip replacement?

An abduction pillow.

Why should low chairs and couches be avoided after hip replacement?

They increase hip flexion beyond 90 degrees.

What sitting position is recommended after hip replacement?

Firm chair with hips above knees.

What assistive devices help maintain hip precautions?

Reacher, sock aid, long-handled shoehorn, elevated toilet seat.

How should patients turn after hip replacement?

Turn the entire body instead of twisting.

What home safety teaching should be provided after hip surgery?

Remove loose rugs, improve lighting, keep items within reach, use firm chairs, take pain medication before PT if prescribed.

What is the most common cause of amputation?

Peripheral vascular disease, especially diabetes.

What other indications may require amputation?

Trauma, infection, ischemic gangrene, severe injury, rest pain.

What is an open (guillotine) amputation?

An amputation left open initially due to severe infection with delayed closure.

What is a closed (flap) amputation?

An amputation where a skin flap closes the residual limb during surgery.

What is the goal when determining amputation level?

Preserve as much limb length as possible.

What are the advantages of a below-knee amputation (BKA)?

Better mobility, easier prosthetic use, greater independence.

What disadvantage is associated with an above-knee amputation (AKA)?

Requires more energy for walking and causes greater functional limitations.

What should be assessed on the residual limb after amputation?

Hemorrhage, drainage, dressing integrity, healing, infection.

Why is a tourniquet kept at the bedside after an amputation?

To control life-threatening hemorrhage if it occurs.

How long may the residual limb be elevated after surgery?

Only during the first 24 hours.

Why should prolonged elevation be avoided after the first day?

To prevent flexion contractures.

What helps reduce edema and shape the residual limb?

Elastic compression wrapping.

What emotional responses are common after amputation?

Grief, anger, depression, withdrawal.

How should phantom pain be managed?

Treat it as real pain using medications, ROM exercises if allowed, visual imagery, and other pain management techniques.