Editing Medical-Surgical Nursing (section)

== Musculoskeletal Disorders ==

=== Fractures and Immobilization ===

Findings include pain, deformity, swelling, crepitus, loss of function, and ecchymosis. Neurovascular assessment distal to any injury, cast, or splint is performed routinely and includes pain, pallor, pulse, paresthesia, paralysis, and poikilothermia, with temperature, capillary refill, and movement documented.

Cast care: elevate the extremity above heart level for the first day or two, apply ice as ordered, handle a wet plaster cast with palms rather than fingertips, allow air drying without covering, never insert objects under the cast to scratch, and keep the cast dry. Report increasing pain, numbness, foul odor, drainage, or a hot spot.

Traction: maintain continuous pull with weights hanging freely and off the floor, keep the patient in proper alignment, do not remove weights without an order, and provide pin site care for skeletal traction while monitoring for infection.

Nursing application: compartment syndrome is caused by increased pressure within a fascial compartment that compromises circulation. The hallmark is pain out of proportion to the injury that is unrelieved by opioids and increases with passive stretch, along with paresthesia and tightness. Pulselessness is a very late finding, so waiting for a lost pulse is a serious error. Report immediately, elevate no higher than heart level, and prepare for possible fasciotomy. Do not elevate above the heart, because that reduces arterial perfusion.

Fat embolism syndrome typically occurs twenty-four to seventy-two hours after fracture of a long bone or pelvis and presents with sudden dyspnea, hypoxemia, tachycardia, confusion, and a petechial rash over the chest, neck, and axillae. Support oxygenation and notify the provider urgently.

=== Joint Replacement ===

After total hip arthroplasty with a posterior approach, the patient avoids flexing the hip beyond ninety degrees, avoids crossing the legs or adducting past midline, and avoids internal rotation. Use an abduction pillow, a raised toilet seat, a high chair with arms, and a reacher, and do not bend to put on socks or shoes. Report sudden severe pain, shortening with external rotation of the affected leg, or a popping sensation, which suggest dislocation.

After total knee arthroplasty, encourage continuous passive motion if ordered, early ambulation, and quadriceps strengthening, and control pain before therapy so the patient can participate.

For both, venous thromboembolism prophylaxis and infection monitoring are central nursing responsibilities.

=== Chronic Bone and Joint Disease ===

Osteoarthritis is degenerative cartilage wear producing asymmetric joint pain that worsens with use and improves with rest, with morning stiffness typically lasting under thirty minutes and Heberden and Bouchard nodes. Rheumatoid arthritis is a systemic autoimmune disease producing symmetric joint inflammation with morning stiffness lasting more than an hour, fatigue, low-grade fever, and eventual deformity. Heat helps rheumatoid stiffness before activity; cold helps acute inflammation and swelling.

Osteoporosis is loss of bone density, often silent until a fracture occurs, with vertebral compression fractures, kyphosis, and height loss. Teach adequate calcium and vitamin D, weight-bearing exercise, smoking and alcohol reduction, and fall prevention. Bisphosphonates are taken in the morning on an empty stomach with a full glass of plain water, and the patient must remain upright for at least thirty minutes to prevent esophageal erosion.

Gout is uric acid crystal deposition producing sudden severe pain, redness, and swelling, classically in the great toe. Teach hydration, weight management, and avoidance of purine-rich foods such as organ meats, sardines, anchovies, and beer.