STATION ONE: ASSESSMNMET OF INJURED ANKLE AND ACE WRAP
1. In assessing D.M.'s injured ankle, what should be evaluated?
Pulses, pain (at rest or with movement), paresthesia, paralysis, pallor. Note swelling, discoloration
(bruising), and range of motion.
2. What will initial management of the ankle involve to prevent further swelling and injury?
The ankle will be immobilized with the leg elevated above the patient's heart. Ice bags should be
applied to the ankle, and elastic wrap should be used to apply mild compression. (RICE: Rest, Ice,
Compression, Elevation)
3. You note significant swelling over the fourth and fifth metatarsals. How would you further evaluate this
finding?
Apply pressure over the area to assess for pain. If pain is present, the x-ray examination should include
the ankle as well as the foot. Inversion injuries commonly result in fracture of the fifth metatarsal.
4. Describe the technique for applying an elastic wrap. Give the rationale. Wrap your partner’s ankle.
The elastic wrapping should begin distally to prevent milking of venous blood flow and extravascular
fluid downward. The wrap should be unrolled with little tension and should be smooth and without
wrinkles. A figure-of-eight wrap should be used at the ankle joint. Capillary refill should be checked
after application, and the skin over the toes should be checked for warmth; observe skin color for pallor.
STATION TWO: CRUTCHES
1. Describe how you will measure DM for the proper crutch fit. Measure your partner.
Measurement for an axillary crutch includes the patient's height, the angle of elbow flexion, and the
distance between the crutch pad and the axilla. When crutches are fitted, ensure that the length of the
crutch is two to three finger widths from the axilla and position the tips approximately 2 inches lateral
and 4 to 6 inches anterior to the front of the patient's shoes (Figure 39-14).
Position the handgrips so the axillae are not supporting the patient's body weight. Pressure on the
axillae increases risk to underlying nerves, which sometimes results in partial paralysis of the arm.
Determine correct position of the handgrips with the patient upright, supporting weight by the handgrips
with the elbows slightly flexed at 20 to 25 degrees. Elbow flexion may be verified with a goniometer
(Figure 39-15). When you determine the height and placement of the handgrips, verify that the distance
between the crutch pad and the patient's axilla is approximately 2 inches (two to three finger widths)
(Figure 39-16).
2. When instructing D.M. to use crutches, D.M. states that he "likes it better" when the crutches rest under
his arms while he walks with the crutches. Is this correct? Explain.
He needs to bear his weight on his hands, wrists, and arms. The axillary area should never be used to
support the weight; this can result in nerve damage. The top of the crutches should be two finger widths
below the axilla. Arms should be kept straight with hands on the grips. Place crutches far enough apart
to allow the body to swing through unimpeded.
3. Describe the two-point, three-point, and four-point gait. What is the difference in each of these?
Demonstrate each of these gaits while your partner critiques your technique.
Patients assume a crutch gait by alternately bearing weight on one or both legs and on the crutches.
Determine the gait by assessing the patient's physical and functional abilities and the disease or injury
that resulted in the need for crutches. This section summarizes the basic crutch stance and the four
standard gaits: four-point alternating gait, three-point alternating gait, two-point gait, and swing-through
gait.
The basic crutch stance is the tripod position, formed when the crutches are placed 15 cm (6 inches) in
front of and 15 cm (6 inches) to the side of each foot (Figure 39-17). This position improves the
patient's balance by providing a wider base of support. The body alignment of the patient in the tripod
position includes an erect head and neck, straight vertebrae, and extended hips and knees. The axillae
should not bear any weight. The patient assumes the tripod position before crutch walking.
Four-point alternating, or four-point, gait gives stability to the patient but requires weight bearing on
both legs. Each leg is moved alternately with each opposing crutch so three points of support are on the
floor at all times (Figure 39-18, A).
Three-point alternating, or three-point, gait requires the patient to bear all of the weight on one foot. In a
three-point gait the patient bears weight on both crutches and then on the uninvolved leg, repeating the
sequence (see Figure 39-18, B). The affected leg does not touch the ground during the early phase of
the three-point gait. Gradually the patient progresses to touchdown and full weight bearing on the
affected leg.
The two-point gait requires at least partial weight bearing on each foot (see Figure 39-18, C). The
patient moves a crutch at the same time as the opposing leg so the crutch movements are similar to arm
motion during normal walking.
Individuals with paraplegia who wear weight-supporting braces on their legs frequently use the swingthrough gait. With weight placed on the supported legs, the patient places the crutches one stride in
front and then swings to or through them while they support his or her weight.
4. You instruct D.M. on using the three-point gait with the crutches. Which would be the correct first step
for the three-point gait?
a.
b.
c.
d.
Step first with the affected leg.
Step first with the unaffected leg.
Step first with both crutches and the affected leg.
Step first with the affected leg and the crutch opposite of the affected leg.
Three-point gait requires the patient to bear all weight on one foot and is useful for patients with a
broken leg or sprained ankle. The weight is born on the unaffected leg and then on both crutches.
No weight is placed on the affected leg.
5. How would you teach a patient that is non-weight bearing to go up and down steps using crutches?
Practice with your partner going up and down steps.
When ascending stairs on crutches, the patient usually uses a modified three-point gait (Figure 39-19).
He or she stands at the bottom of the stairs and transfers body weight to the crutches. He or she
advances the unaffected leg between the crutches to the stairs. The patient then shifts weight from the
crutches to the unaffected leg. Finally he or she aligns both crutches on the stairs. The patient repeats
this sequence until he or she reaches the top of the stairs.
A three-phase sequence is also used to descend the stairs (Figure 39-20). The patient transfers body
weight to the unaffected leg. He or she places the crutches on the stairs and begins to transfer body
weight to them, moving the affected leg forward. Finally the patient moves the unaffected leg to the
stairs with the crutches. The patient repeats the sequence until reaching the bottom of the stairs.
6. How would you instruct a non-weight bearing patient to sit in a chair with crutches? Practice with your
partner sitting in a chair using crutches.
As with crutch walking and crutch walking up and down stairs, the procedure for sitting in a chair
involves phases and requires the patient to transfer weight (Figure 39-21). First the patient positions
himself or herself at the center front of the chair with the posterior aspect of the legs touching the chair.
Then the patient holds both crutches in the hand opposite the affected leg. If both legs are affected, as
with a person with paraplegia who wears weight-supporting braces, the patient holds the crutches in the
hand on his or her stronger side. With both crutches in one hand, the patient supports body weight on
the unaffected leg and the crutches. While still holding the crutches, the patient grasps the arm of the
chair with the remaining hand and lowers his or her body into it. To stand the procedure is reversed; and
the patient, when fully erect, assumes the tripod position before beginning to walk.
STATION THREE: HIP FRACTURE/WALKER
1. List at least four risk factors for hip fractures.
 Age (high risk for falls)
 Decreased estrogen (menopause) without estrogen replacement therapy or hormone replacement
therapy
 Smoking
 Lack of exercise
 Corticosteroid therapy
 Antimetabolite therapy
 RA
 Long-term use of proton pump inhibitors for GERD
 Personal or family history of fractures
 Osteoporosis
2. Why is S.P. receiving enoxaparin (Lovenox) and warfarin (Coumadin)?
Orthopedic patients fall into a high-risk category for venous thromboembolism (VTE) (deep vein
thrombosis [DVT] and pulmonary embolus [PE]). Enoxaparin is a low-molecular-weight heparin that
has an effect on clotting factors but acts higher in the clotting cascade than heparin. It binds less to
nonspecific plasma proteins, so bioavailability is increased, which helps maintain a constant level of
anticoagulation. Enoxaparin is used in combination with warfarin until a therapeutic level of warfarin
can be reached. Because this can take up to 72 to 96 hours, enoxaparin is used in the early postoperative
period to prevent thrombosis and then discontinued after at least 5 days as long as the INR is between 2
and 3. Warfarin therapy continues for about 5 to 6 weeks after surgery; some physicians might
recommend warfarin for 3 months
3. S.P. had an arthroplasty. Describe the difference in and arthroplasty and open reduction and internal
fixation (ORIF) of the hip.
Arthroplasty is an operative procedure to place an artificial joint. It is also known as a total hip
replacement. It replaces the entire hip joint with a prosthetic (artificial) joint system.
ORIF surgery involves the insertion of a metal pins, screws, rods, and plates to immobilize and stabilize
a hip fracture and allow for healing
4. Discuss proper leg alignment of S.P.'s operative leg.
Extremes of internal rotation must be avoided. Abduction of the hip should be maintained by using
pillows or an abduction pillow splint between S.P.'s legs. Pillows are also placed bilaterally under
calves. It is important to prevent adduction of the hip
Extreme flexion of the hip is avoided by elevating the head of bed (HOB) no more than 45 degrees on
the first postoperative night until after the PT evaluation. The HOB can be elevated to 60 degrees after
the patient gets out of bed the next morning.
S. P. is learning to use a walker to assist with ambulation.
5. Why does a walker provide good support for S. P.?
A walker is a lightweight, movable device that stands about waist high and consists of a metal frame
with handgrips, four widely placed sturdy legs, and one open side (Figure 39-12). Because it has a wide
base of support, the walker provides great stability and security during walking.
6. How do you correctly measure S.P for a walker? Measure your partner for a walker.
You measure walkers by having patients relax their arms at the side of their body and stand up straight.
The top of the walker should line up with the crease on the inside of the wrist (American Academy of
Orthopaedist Surgeons, 2015). Elbows should be flexed about 15 to 30 degrees when standing inside
the walker, with hands on the handgrips.
7. How would you instruct S. P. to properly use her walker for ambulating?
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A patient holds the handgrips on the upper bars, takes a step, moves the walker forward, and takes
another step. A walker requires a patient to lift the device up and forward. Teach patients how to
use walkers safely and avoid risk of falling.
Keep your back straight. Don't hunch over the walker.
Check to be sure the rubber tips on your walker's legs are in good shape. If they become uneven or
worn, you can purchase new tips at a drug store or medical supply store.
8. What do you teach S. P. about maneuvering stairs with a walker?
Never climb stairs or use an escalator with your walker.
9. How should S. P. sit in a chair using her walker?
To sit, back up until your legs touch the chair. Use your hands to feel behind you for the seat of the
chair. Slowly lower yourself into the chair.
STATION FOUR: CANES
S. P. is progressing well in rehab and is ready to learn the fundamentals of using a cane.
1. How would you measure the proper length of a cane for S. P.? Measure your partner for a cane.
A person's cane length is equal to the distance between the greater trochanter and the floor
2. List the 2 types of canes and describe the differences in them.
Two common types of canes are the single straight-legged cane and the quad cane.
The single straight-legged cane is more common and is used to support and balance a patient with
decreased leg strength.
The quad cane provides the most support and is used when there is partial or complete leg paralysis or
some hemiplegia (Figure 39-13).
3. Describe how you would teach S. P. to use the cane for walking? Practice with your partner walking
with a cane.
Have the patient keep the cane on the stronger side of the body. For maximum support when walking,
the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. He
or she moves the weaker leg forward to the cane so body weight is divided between the cane and the
stronger leg. The patient then advances the stronger leg past the cane so the weaker leg and the body
weight are supported by the cane and weaker leg. During walking the patient continually repeats these
three steps. The patient needs to learn that two points of support such as both feet or one foot and the
cane are on the floor at all times.
4. How will S. P. maneuver stairs using her cane? Practice with your partner climbing stairs using a cane
and going down stairs using a cane.
To climb stairs, place your cane in the hand opposite your injured leg. With your free hand, grasp the
handrail. Step up on your good leg first, then step up on the injured leg. To come down stairs, put your
cane on the step first, then your injured leg and then, finally, your good leg, which carries your body
weight.
STATION FIVE: FEMUR FRACTURE/SKELETAL TRACTION
1. What is the purpose or traction?
Traction is the application of a pulling force to an injured or diseased body part or extremity. Traction is
used to
(1) Prevent or reduce pain and muscle spasm (e.g., whiplash, unrepaired hip fracture),
(2) Immobilize a joint or part of the body,
(3) Reduce a fracture or dislocation, and
(4) Treat a pathologic joint condition (e.g., tumor, infection).
Traction is also indicated to
(1) Provide immobilization to prevent soft tissue damage,
(2) Promote active and passive exercise,
(3) Expand a joint space during arthroscopic procedures, and
(4) Expand a joint space before major joint reconstruction.
Traction devices apply a pulling force on a fractured extremity to attain realignment
while countertraction pulls in the opposite direction. The most common types of traction are
skin traction and skeletal traction.
2. Describe balanced suspension traction.
Skeletal traction, generally in place for longer periods than skin traction, is used to align injured bones
and joints or to treat joint contractures and congenital hip dysplasia. It provides a long-term pull that
keeps the injured bones and joints aligned. To apply skeletal traction, the surgeon inserts a pin or wire
into the bone, and weights are attached to align and immobilize the injured body part. Weight for
skeletal traction ranges from 5 to 45 lb (2.3 to 20.4 kg). The use of too much weight can result in
delayed union or nonunion. The major complications of skeletal traction are infection at the pin
insertion site and the effects of prolonged immobility.
3. You enter J.F.'s room for the first time. What aspects of the traction will you inspect?

Inspect body alignment. Does the traction maintain the leg in proper alignment with the rest of
the body (not at an angle)?
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Inspect the weights to make certain they hang freely and are well off of the floor.
Inspect all knots to make certain they are secure and away from the pulleys.
Inspect the ropes to make certain they move freely in the pulleys and are not frayed.
Inspect all pulleys to make certain they are tightly attached to the support bars.
Inspect the position of the sling that supports the lower leg. Make certain the Achilles tendon
does not support the weight of the entire lower leg.
Inspect the skin around the skeletal pin. Make certain it is not in contact with the frame.
Inspect the skeletal pin through the left femur. Make certain it is not in contact with the frame.
4. When inspecting the skeletal pin sites, you note that the skin is reddened for an inch around the pin on
both the medial and lateral left leg. What does this finding indicate, and what action will you take?
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Slight redness would be expected, but redness that extends for a 1-inch radius from the pin
indicates a possible infection.
Obtain wound cultures as needed. Be sure to obtain cultures before applying any cleansers or
antibiotics.
Perform pin care according to physician preference or institutional policy. A chlorhexidine
2mg/mL solution, or normal saline, may be used for cleaning.
Use sterile technique.
Check white blood cell (WBC) count results; note trends and look for increase.
Monitor vital signs (VS), including Spo2.
Frequently an antibiotic ointment is placed around the pin sites. The decision depends on
prescriber preference. Neosporin produces a higher risk for allergic reactions because it contains
several different antibiotics: bacitracin, neomycin, and polymyxin B. Frequently bacitracin is
used.
5. What other key points of the assessment will you document in the patient's record?
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The traction device: leg alignment, weights, and position of weights
The condition of the skin around the pins, especially if any redness is noted
Any significant findings in other body systems, such as cardiac, respiratory, gastrointestinal (GI),
genitourinary (GU)
Assessment of the skin over pressure areas and on the affected limb
Patient's level of consciousness (LOC) and emotional status
6. You find J.F.'s body in the lower 75% of the bed and her left upper leg at an exaggerated angle (more
than 45 degrees). The knot at the end of the bed is caught in the pulley and the 20-pound weight is
dangling just above the floor. What are you going to do?
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Get adequate help to lift J.F. to the head of bed (HOB).
Have one person pull up slightly on the 20-pound traction weight and another person lift up slightly
on the 5-pound suspension weight so that the group can move J.F. toward the HOB.
Have both people gradually release their weight at the same time and observe the left upper leg
return to a 45-degree angle.
You must recheck the traction mechanics after each position change
7. When you lift J.F., you notice that her sheets are wet. You decide to change J.F.'s linen. How would
you accomplish this task?
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First, determine why the sheets are wet. If the bed is wet with perspiration, J.F. will need to have a
bath blanket placed beneath her torso. If she spilled water in the bed, then the bed can be made with
the same quantity and type of linen as that removed from the bed. Check to make certain the
catheter or IV line is not leaking.
Obtain all of the linen that will be needed, and arrange it in the order that it will be required to
change the bed quickly.
Lift J.F. vertically while two people quickly strip then remake the bed from the top down.
Lower J.F. onto the bed while having everyone gently and simultaneously pull on the sheets to
ensure a wrinkle-free surface beneath J.F.
8. J.F. tells you that she feels like she needs to have a bowel movement (BM) but it is too painful to sit on
the bedpan. How would you respond?
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Show J.F. a fracture pan and tell her that the flat end fits under her buttocks and is not as
uncomfortable as the larger pans.
Obtain an order for a trapeze bar, if permitted, so that she can help to raise her body off the bed to
use the bedpan.
Place her on the fracture pan and provide privacy.
Make certain she has her call light, and instruct her to turn it on when she is finished.
Powder the flat end of the pan so that her skin does not stick to the pan.
9. J.F. expels a few small, hard, round pieces of stool. What could be done to promote normal elimination?
Institute a bowel regimen (stool softeners, roughage, increased fluid intake, and so on). • Document
quality and quantity of each BM.
10. What is the likely cause of the problem and what needs to be done to encourage healing?
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The most likely cause is a superinfection caused by Candida organisms.
Wash the area with soap and water. Dry thoroughly and allow maximal exposure to the air.
Separate opposing skin surfaces by placing a clean, dry washcloth or gauze pad between the skin
surfaces.
Institute skin care protocol or inform the wound or skin care specialist, if available, and the
physician; follow prescribed treatment.
11. You ask J.F. what she is doing to exercise while she is confined to the bed. She looks surprised and
states that she isn't doing anything. What activities can J.F. engage in while on bed rest?
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She can pump her right ankle to facilitate circulation in her right leg.
Use the trapeze (if ordered) to lift her upper body off of the bed and reposition herself.
Obtain a physical therapist (PT) or occupational therapist (OT) consultation if not already ordered.
The PT will have elastic bands that can be tied to the side rails to offer resistance to upper
extremities, handgrip devices that can be squeezed, putty, and so on.
12. You realize that maintaining skin integrity is a challenge in J.F.'s case. What measures will you take to
prevent skin breakdown?
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Institute pressure point monitoring.
Pad any skin that comes into contact with the traction device.
Frequently reposition J.F.
Encourage her to use the trapeze bar to frequently reposition herself.
Do skin checks every shift
13. Although J.F. is recovering nicely, she is becoming increasingly withdrawn. You enter her room and
find her crying. She tells you that she is all alone here, that she misses her family terribly. You know
that her son is flying into town tomorrow but will only be able to stay a few days. What can be done so
that J.F. benefits from her family support system?
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Call J.F.'s son and have him bring pictures of the grandchildren for J.F.
Obtain a laptop computer with Internet access and Skype, FaceTime, or other similar programs for
real-time conversations, in addition to other social media programs. Or have the grandchildren taperecord messages and send them to J.F.
Arrange for uninterrupted time for phone calls.
Ask children to draw pictures for Grandma's room and tape the pictures to the crossbar over J.F.'s
bed (don't just hang them on the wall).
Request a social worker consultation, recreational therapy, and visits by volunteers and offer to
arrange a pastoral care visit.
Contact the local certified pet therapy program, if available.
Contact the case manager to begin discharge and rehabilitation teaching and planning.
Get her more involved in her rehabilitation plans
STATION SIX: FEMUR FRACTURE/BUCK’S TRACTION
1. Considering her medical history and that she has been without her medications for at least 24 hours,
explain her current VS.
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One would expect that she should be hypertensive by this time. However, several factors might have
contributed to her low blood pressure (BP), high pulse, and fast respirations.
She has not had fluid intake for 24 hours, leading to a significant net fluid loss.
Her current injury might have contributed to significant compartmentalized intravascular fluid loss.
She has lost fluid through urinary and bowel incontinence as well as insensible loss (respiratory).
This net hypovolemia, characterized by decreased intravascular volume, results in a low BP.
To compensate for decreased circulating blood volume, the pulse increases to try to maintain an
adequate cardiac output (CO). The loss of red blood cells (RBCs) into the thigh compartment
contributes to generalized hypoxemia; respiratory drive increases in an attempt to maintain
oxygenation
2. Based on her history and your initial assessment, what three priority interventions would you expect to
be initiated?
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Titrate administration of oxygen by nasal cannula to keep Spo2 above 92%.
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Start intravenous (IV) lactated Ringer's (LR) or normal saline solution, and administer a fluid
challenge (administer 200mL over 30 minutes, evaluate VS, then administer another 200mL over 30
minutes). Then continue to administer IV fluids to support VS and urinary output.
Monitor lung sounds and VS for fluid overload because of her history of angina and risk for heart
failure (HF).
3. M.C.'s daughter states, "Mother is always so clear and alert. I have never seen her act so confused.
What's wrong with her?” What are three possible causes for M.C.'s disorientation that should be
considered and evaluated?
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Dehydration and hypovolemia with associated electrolyte imbalances and hypoxemia
Head injury at time of fall
Cerebrovascular accident (CVA) or cardiac dysrhythmias before the fall, resulting in a loss of
balance or temporary loss of consciousness
 Delirium.
4. What are the five Ps that should guide the assessment of M.C.'s right leg before and after surgery?
Pulses, pain, paresthesia, paralysis, and pallor
5. In evaluating M.C.'s pulses, you find her posterior tibial pulse and dorsalis pedis pulse to be weaker on
her right foot than on her left. What could be a possible cause of this finding?
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This might be caused by compartment syndrome, in which vascular supply is compressed by
excessive swelling. This is an emergency condition.
Hypovolemia might be a contributing factor if the BP remains low.
Peripheral vascular disease could be more severe in one leg than in the other.
6. You carefully monitor M.C.'s right extremity for compartment syndrome. Which of these is a
characteristic of compartment syndrome? Select all that apply.
a. Warmth of the extremity
b. Pain distal to the injury that is not relieved by opioid analgesics
c. Numbness and tingling of the extremity
d. Pallor of the extremity
e. Petechiae over the extremity
7. In planning further care for M.C., list four potential complications for which M.C. should be monitored.
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Risk for fat emboli is high in the presence of long bone fracture.
Venous thromboembolism might occur as a result of immobility.
Compartment syndrome might occur because of excessive swelling into tissue that compresses the
vasculature and nerve tissue.
Hemorrhage into muscle might result in significant blood loss and shock.
M.C.'s history places her at higher risk for developing HF, CVA, or myocardial infarction (MI).
8. As you assess the traction, you check the setup and M.C.'s comfort. Which of these are characteristics
of Buck's traction? Select all that apply.
a. The weights can be lifted manually as needed for comfort.
b. Weights need to be freely hanging at all times.
c. Pin site care is an essential part of nursing management for Buck's traction.
d. A Velcro boot is used to immobilize the affected leg and connect to the weights.
e. Weights used for Buck's traction are limited to 5 to 10 pounds.
9. Describe Buck’s traction.
Buck's traction for a hip fracture will use a Velcro boot to immobilize the affected leg and connect to the
weights; the weights are limited to 5 to 10 pounds and need to be freely hanging at all times. The
weights should never be manually lifted. Buck's traction is skin traction and does not involve the use of
surgically inserted pins.
STATION TEN: CAST CARE
1. Neurovascular checks – What does this consist of?
Pain
A validated age appropriate pain assessment tool should be used to determine patients pain levels, this
same scale should be used throughout the patient hospital stay to enhance reliability of assessment.
The most important indicator of neurovascular compromise is pain disproportionate to the injury. Pain
associated with compartment syndrome is generally constant however worse with passive movement to
extension and is not relieved with opioid analgesia.
Indication of pain in non-verbal patients includes restlessness, grimacing, guarding, tachycardia,
hypotension, tachypnoea or diaphoresis.
If pain is disproportionate to injury notify medical team.
Sensation
If neurovascular compromise is present, patients may report decreased sensation, loss of sensation,
numbness, tingling or pins and needles.
Altered sensation may be a result of a nerve block or epidural, this should be documented on the patient
neurovascular chart.
The medical team should be contacted if the child experiences any deviation from the baseline
assessment.
Motor function
Active movement: Ability to voluntarily extend and flex an extremity or digit.
Passive movement: Assessor able to extend and flex an extremity or digit.
Note amount of pain on movement of the limb
It is important to compare movement of digits bilaterally and to the baseline observations as some
patients may have had limited or no movement previous to injury.
Contact medical team if there is any deterioration in neurovascular assessment.
Peripheral vascular assessment
2. Assess for compartment syndrome – What is this and how does the nurse assess for it?
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Compartment syndrome is a serious complication of musculoskeletal injury. Compartment syndrome
results from an increase in pressure inside a compartment which comprises of muscles and nerves and is
enclosed by fascia, fascia is inelastic and does not expand to increased volume or pressure. When the
compartment pressure increases, nerves and then muscles become compressed resulting in decreased
blood flow and tissue perfusion, muscle ischemia and loss or altered sensation. This will progressively
deteriorate until pressure is relieved inside the fascia. Compartment syndrome is a surgical emergency
to relieve the pressure or reduce volume within the compartment, which will preserves blood supply and
tissue function. Early recognition of neurovascular deterioration is crucial in limb salvage or survival.
Indications of compartment syndrome
Pain: The first and most reliable sign of compartment syndrome. Pain out of proportion to injury,
extreme pain on passive movement and pain unrelieved with opioid analgesia.
Paralysis: Is generally a late sign of compartment syndrome and results from prolonged nerve
compression or muscle damage. Paralysis presents with inability to actively move the limb and
increased pain on passive movement that is not relieved in extension.
Paresthesia: Results from nerve compression and generally is indicated by pins and needles, tingling or
numbness.
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Pallor: Indicates arterial insufficiencies below the level of injury, below the level of injury will appear
cold and pale.
Temperature: Coolness of the limb distal to injury indicates decreased arterial supply.
Capillary refill: Indicates limb perfusion, capillary refill more than 3seconds indicates inadequate limb
perfusion.
Pulselessness: Absent pulse is a late sign and indicates tissue death.
Swelling and Increased Pressure: Is a result increased intercompartment pressure, skin presents tight
and shiny.
3. What are the five P’s? What is the 6th P?
1) Pain
Pain is the universal symptom in compartment syndrome. While significant pain is almost always
present as the pressure within the limb compartment rises, we may mistakenly attribute it solely to the
injury itself. When pain seems dramatically out of proportion for the severity of the mechanism,
consider the possibility of a compartment syndrome and look a little closer.
The pain typically felt with compartment syndrome is a dull, deep aching that is difficult to localize.
Pain that increases upon manipulation of the muscle is also suspect for compartment syndrome.
2) Paresthesia
This is that hallmark “pins-and-needles” sensation that we feel when one of our limbs has been without
adequate circulation for a period of time. If you’ve ever had a crossed leg become temporarily numb
while you were sitting down and then felt a rush of pin-prick sensations as circulation returned, you’ve
felt two different types of paresthesia (numbness and tingling).
Numbness isn’t typically associated with our run-of-the-mill limb injuries. It can indicate nerve damage
or it might suggest a progressing compartment syndrome.
3) Pallor
Pale, shiny skin distal to the injury should raise our suspicion of compartment syndrome. Bruising nay
also be present.
4) Paralysis
More common in crush injuries, the total inability to move the limb distal to the injury might suggest
compartment syndrome. If the limb is still intact, some movement should be possible in the distal
extremity. If the limb is lifeless we should suspect significant muscle and nerve disruption and, possibly
compartment syndrome.
5) Pulselessness
We normally associate pulelessness with the severely angulated limb or massive soft tissue damage. But
the absence of a pulse distal to the extremity can be caused by any mechanism that produces a tourniquet
type effect.
A strong pulse certainly doesn’t rule out compartment syndrome. If the artery you are palpating doesn’t
pass through the affected compartment, the pulse may be just fine. But finding a diminished or absent
pulse in an otherwise intact limb should lead the caregiver to consider compartment syndrome. Also
consider that delayed capillary refill may be a more subtle but earlier sign of decreased circulation in
this patient.
6) Poikilothermia
Always a great buzz-word to drop at cocktail parties, the specific definition of poikilothermia is an
organism or body part that normalizes its temperature with its surrounding temperature. If something
attempts to achieve room temperature, it is poikilothermic.
In the context of compartment syndrome it refers to the finding of differing temperatures between the
affected limb and the uninjured limb. Place a hand on the painful limb just distal to the injury or the site
of pain. Then place your other hand on the opposite limb in the same location. If the affected limb feels
cooler than the unaffected limb, this suggests that the injured limb is unable to thermoregulate.
Anticipate that you would only find differences in temperature with significant and advanced
compartment syndrome.
4. Describe to two types of casts?
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Casts are custom-made to fit and support injured limbs. There are two main types of casts:
Fiberglass casts. Fiberglass is a type of plastic that can be shaped. Fiberglass casts are typically lighter
and more durable than are traditional plaster casts. Air circulates more freely inside a fiberglass cast.
Also, X-rays penetrate fiberglass casts better than plaster casts. This is helpful if your child's doctor
wants to use an X-ray to examine your child's bones while he or she is still wearing the cast. Fiberglass
casts are available in different colors.
Plaster casts. Plaster casts are easier to mold for some uses than are fiberglass casts. Also, plaster casts
are typically less expensive than fiberglass casts.
5. What can be done to reduce swelling?
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Swelling can cause your child's cast to feel tight and uncomfortable. To reduce swelling:
Elevate the affected area. For the first 24 to 72 hours after your child's cast is applied, use pillows to
raise the cast above the level of your child's heart. If possible, keep the cast raised even while your child
is asleep.
Keep moving. Encourage your child to frequently move the fingers or toes of his or her injured limb.
Apply ice. For the first 48 to 72 hours after your child's cast is applied, loosely wrap an ice pack
covered in a thin towel around your child's cast. Apply ice to the cast — not the skin — at the area of
the injury for 15 to 30 minutes every few hours or so. There's no need to apply the ice during sleep.
6. How do you teach a patient to relieve itching under the cast?
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A cast can cause your child's underlying skin to feel itchy. To relieve itchy skin:
Turn a hair dryer on a cool setting and aim it under the cast
Ask your child's doctor about giving your child an over-the-counter antihistamine
Don't allow your child to stick objects, such as a coat hanger, inside the cast to scratch his or her
skin. This could cause an injury or infection.
7. What discharge teaching is important when going home with a cast?
Contact the care provider immediately if the patient:
 Feels increasing pain and tightness in the injured limb
 Feels numbness or tingling in the injured hand or foot
 Feels burning or stinging under the cast
 Develops excessive swelling below the cast
 Can't move the toes or fingers of his or her injured limb or they become blue or cold
 Develops a crack, soft spots or a foul odor in his or her cast or gets the cast soaking wet and doesn't
dry it properly
 Says the cast feels too tight or too loose
 Develops red or raw skin around the cast
 Develops a fever of 101 F (38.3 C) or higher