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  • Soft tissue injury produced by a blunt force, kick, or fall.


  • Ecchymosis (Bleeding into the injured  part) .
  • Swelling.

Nursing Responsibility   

  • Affected part should be elevated.
  • Cold compress for 1st 24 hr and after that warm heat application.
  • Apply pressure bandage to control bleeding and hematoma formation and swelling.
  • Assess neurovascular function.
  • Avoid excessive exercises of injured part.


  • Microscopy tearing of muscle or tendon caused by excessive stretching or over use.  


  • Application of ice.
  • Activity limitation.
  • Anti inflammatory and muscle relaxants.
  • Surgical repair may be required for a severe strain.


  • Injury to the ligament surrounding the joint and caused by twisting motion.


  • Pain on passive movement of joint.


  • R-Rest
  • I –   Ice application.
  • C– Compression bandage.
  • E– Elevate and support joints.
    • Cast application to immobilize the part.
    • Surgery if severe damage.


  • Musculotendinous or rotator cuff of the shoulder sustains a tear, usually as a result of trauma.


  • Shoulder pain.
  • Inability to maintain abduction of the arm.
  • Drop arm test+ (Arm will be in a dropped state).


  • NSAID, Pain medication.
  • Physical therapy.
  • Provide sling support.
  • Ice or heat application.
  • Prepare the patient for surgery for complete tear.


  • Break in the continuity of the bone caused by trauma.


  • Complete   The bone is completely separated a break into two parts.
  • Incomplete A partial break in the bone.    
  • Simple /closed   Skin over the fractured area is intact.    
  • Compound/open Bone is exposed to air through the break.
  • Green stick One side of the bone is broken and the other is bent common in children.
  • Comminuted Bone is crushed with 3 or more fragments.    
  • Transverse   Fracture straight across.    
  • Oblique   Fracture extends in a oblique direction.    
  • Spiral   The break partially encircles bone.
  • Compressed A fractured bone compressed by other bone.    
  • Impacted   Part of the fractured bone is driven into another bone.   
  • Depressed   Fragment of bone is pulled off by ligament or tendon.    
  • Pathological/ Spontaneous   Secondary to other diseases


  • Pain, Swelling, and tenderness over the area.
  • Loss of function.
  • Erythema, edema, ecchymosis.
  • Muscle spasm.
  • Impaired sensation.

Diagnosis: – X-ray and by assessment.


  • Immobilize affected extremity.
  • Apply splint or sling.
  • Cast application.



  • Restore the bone to proper alignment.


  • Closed Reduction

Performed by manual manipulation under LA or GA, and cast may be applied.

  • Open reduction

Involves a surgical intervention.



  • Internal fixation
    • Follows open reduction.
    • Involves the application of screws, plates, pins, or nails to hold the fragments in alignment.
  • External fixation 
    • An external frame is utilized with multiple pin applied through the bone.
    • It provides more freedom of movement than with traction.


  • The exertion of pulling force applied in two directions to reduce and immobilize a fracture.
  • It provides proper bone alignment and reduce muscle spasms.

Nursing Responsibility    

  • Maintain a proper body alignment.
  • Ensure that the weights hang freely and do not touch the floor.
  • Do not remove or lift the weight without a physician’s order.
  • Ensure that pulleys are not obstructed and ropes in the pulleys move freely.
  • Place knots in the ropes to prevent slipping.
  • Check the rope for fraying.


Skeletal traction: – Traction is applied to the bone with pins, wires, or tongs.


Nursing Responsibility    

  • Monitor color, motion, and sensation of the affected extremity.
  • Monitor the insertion sites for redness, swelling or drainage.
  • Provide insertion sites care.

Skin traction: – Traction applied by the use of elastic bandage or adhesive.


  1. Cervical traction 
  • Relieves muscle spasms and compression in the upper extremities and neck.
  • Use a chin pad or head halter to attach the traction.
  • Use powder to protect ears from friction rub.
  • Position the client with the head of the bed elevated 30 to 40 degrees, and attaches the weights to a pulley system over the head of the bed.
  1. Buck’s traction
  • A boot appliance is applied to attach to the traction.
  • Weight is attached to a pulley, allow the weight to hang freely over the edge of bed.
  • Not more than 8 to 10 pounds of weight should be attach.
  • Elevate the foot end of the bed to provide traction.
  1. Russell’s traction
  • Almost the bulk’s traction, it is a skin traction.
  • Slight knee flexion and hip flexion is give with two direction traction horizontal and vertical.
  1. Pelvic traction
  • Use to relieve low back, hip, or leg pain and reduce muscle spasm.
  • Apply the traction snugly over the pelvis and iliac crest and attach to the weight.
  • Hip and knee flexion should be provided to prevent from slipping down in bed and to promote comfort to back muscle.
  1. Bryant’s traction
  • Commonly used for children to treat congenital hip dysplasia.
  • Legs are extended at right angle to the body.
  • Hip and buttock are slightly elevated from the bed.
  • Heals and ankles are free from pressure.
  • Usually used in children between 6 to 18 months.
  1. Balanced Suspension
  • Position the client in low fowler’s.
  • Maintain a 20 degree angle from the thigh to bed.
  • It is used with a skin or skeletal traction.
  • Patient will lye straight not acting as a counter traction.
  • Use to approximate fracture of the femur tibia, or fibula.
  1. Dunlop’s traction
  • Horizontal traction to align fracture of the humerus.
  • Vertical traction maintains the fore arm in proper alignment.

CAST   :-


  • POP (24 to 48 hr for dry)
  • Fiber glass (20 minutes to dry)


  • To provide immobilization of bone and joints after a fracture or injury.

Nursing Responsibility    

  • Keep the cast and extremity elevated.
  • Handle a wet cast with palms of the hand until dry.
  • Turn the extremity. Unless contraindicated so that all side will dry.
  • Heat cannot be used to dry the cast.
  • Cast will appear shiny when dry.
  • Examine the skin and cast for pressure area after 24 hr.
  • Monitor for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness or diminished pulse.
  • Notify the physician and prepare for bivalving or cutting the cast.
  • Petal the cast, maintain smooth edge around the cast to prevent crumbling of the cast material.
  • Monitor temperature, foul odor, drainage and warm on the cast.
  • Monitor for wet spot after 48 hrs, which indicate presence of drainage under the cast.
  • If wet spot present after 48 hr prepare the patient for windowing the cast.
  • Instruct the patient not to stick object inside the cast.
  • Instruct the patient not to apply paints on POP which may cause closure of small pores on the cast.
  • Teach the client to keep the cast clean and dry.
  • Instruct to do isometric exercises to prevent muscle atrophy.

Complication of fracture  

  1. Fat embolism   
  • An embolism originating in the bone narrow that occurs after a fracture of long bone. Usually occurs within 48 hours.


  • Sudden onset of chest pain.
  • Dyspnea, Tachycardia, Tachypnea,
  • Mental status changes.
  • Petechial rash over the upper chest and neck.


  • Notify the physician immediately.
  • Treat symptoms and prevent respiratory failure and death.  
  1. Compartment syndrome   
  • Increase pressure within one or more compartments causing massive compromise of circulation to an area.
  • Leads to decrease perfusion and tissue anoxia.
  • It leads to neuromuscular damage after 4-6 hrs.


  • Increased pain and swelling.
  • Pain with passive motion.
  • Inability to move joints.
  • Loss of sensation (parasthesia).


  • Notify physician immediately   
  1. Infection and osteomyelitis   
  • Due to interruption of the skin integrity, the infection invades bone tissue.


  • Fever, Tachycardia,
  • Pain and Erythema in the area surrounding fracture.
  • Elevated WBC count.


  • Notify the physician.
  • Administrate antibiotics.   


  1. Avascular necrosis
  • Due to decreased blood supply to the bony tissue, this leads to death of bone.


  • Decreased sensation.


  • Notify the physician.
  • Prepare the client for removal of necrotic tissue.
  1. Pulmonary embolism
  • Caused by immobility precipitated by a fracture.


  • Restlessness and apprehension.
  • ABG Changes.
  • Sudden onset of chest pain.


  • Notify the physician.
  • Administer anticoagulation therapy.   


Crutch gate 

  • Four point gait.
  • Three point gait.
  • Two point gait.

4 Point gait    

  • Advance left crutch.
  • Advance Right foot.
  • Advance Right crutch.
  • Advance left foot.
    • Advantages  :-Most stable crutch gait.
    • Requirement: – Partial weight bears on both legs.

3 Point gait   

  • Advance both crutches forward with the affected leg (2 point), shift weight to crutches.
  • Advance unaffected leg and shift weight on to it (3rd point)
    • Advantage :-  Allow the affected leg partially or completely free of weight bearing.
    • Requirements :- Full weight bearing on one leg, balance, and upper body strength.

2 Point gait

  • Advance left crutch and right foot.
  • Advance right crutch and left foot.
    • Advantage: – Faster version of 4 point gait.
    • Requirement: – Partial weight bearing on both leg and balance.

Nursing responsibility    

  • An accurate measurement of client for crutch is important because an incorrect measurement could damage the brachial plexus.
  • The distance between the axilla and the arm pieces on the crutches should be two finger widths in the axilla space.
  • Elbows should be slightly flexed 20 to 30 degrees.
  • Stand on the affected side while ambulating.
  • Never rest on the axillary bars.
  • Instruct the client to look up and downward when ambulating.
  • Stop ambulation if numbness or tingling in the hands or arms occurs.

Assisting the client with crutches To sit and stand    

  • Place the unaffected leg against the front of the chair.
  • Move the crutches to the affected side, and grasp the chair’s arm with the hand on the unaffected side.
  • Flex the knee of the unaffected leg to lower self into the chair while placing the affected leg straight out in front.
  • Reverse the step to move from sitting to a standing position.

Going up and down with crutch

Up to stairs    

  • The client moves the unaffected leg up first.
  • Then the client moves the affected leg and the crutch.

Down the stairs    

  • The client moves the crutches and affected leg down.
  • Then client moves the unaffected leg down.


  • Made up of lightweight material with a rubber tip at the bottom.


  • Stand at a affected side of the client when ambulating.
  • The handle should be at the level of client’s greater trochanter.
  • Client’s elbow should be flexed at a 25 to 30 degree angle.
  • Instruct the patient to hold the cane 4 to 6 inch to the side of the foot.
  • Instruct the client to hold the cane in the hand on the unaffected side so that the cane and weaker leg can work together.
  • Instruct the client to inspect the rubber tip for worn places.


  • Stand adjacent to the client on the affected side.
  • Instruct the client to pull all 4 points of the walker Flat on the floor before putting weight on the hand pieces.
  • Instruct the client to move the walker forward and to walk into it.

Fractured HIP 


  • Intra capsular (broken inside the joint) and Extra capsular (outside joint on trochanteric region)

Intra capsular 


  • Skin traction to immobilize the part preoperatively.
  • Prepare the patient for total hip replacement or internal fixation with replacement of prosthesis.
  • Avoid hip flexion to prevent displacement.

Extra capsular    


  • Balanced suspension traction on Buck’s traction preoperatively.
  • Prepare the patient for internal fixation with nail plate, screws, or wires.
  • Avoid hip flexion before surgery to prevent displacement.

Post operative care    

  • Maintain hip and leg in a proper alignment.
  • Prevent flexion, external or internal rotation.
  • Turn the client to unaffected side only.
  • Do not position the client to the affected side.
  • Maintain leg abduction to prevent internal or external rotation.
  • Use a trochanter roll to prevent external rotation.
  • Do not allow flexion of hips.
  • Elevate the head of the bed 30 to 45 degree for meals only.
  • Avoid weight bearing on the affected leg.
  • Ambulate as prescribed by physician.
  • Keep the operative leg extended, supported, and elevated when getting client out of bed and elevated when getting client out of bed.
  • Avoid low chairs when out of the bed.
  • Monitor wound for infection or hemorrhage.
  • Monitor circulation and sensation at the affected side.
  • Maintain the hemovac or Jackson-pratt drain. If in place; maintain compression to facilitate drainage.
  • Normal drainage is 30ml/8hr; when it become 30ml/24 hr can be remove.
  • Use antiembolism stocking.
  • Avoid crossing the legs. And Do not bending from the waste.


Total knee Replacement   

  • Implantation of a device to substitute for the femoral condyles and tibial joint surface.

Post opp Management 

  • Monitor the incision for drainage and infection.
  • Maintain a hemovac or Jackson-pratt drain if in place.
  • Begin continuous passive motion exercise after 24 to 48 hr postoperatively with working splint and provide moderate knee flexion and extension.
  • Administer analgesics before CPM (continuous passive motion) exercise.
  • Leg should not be dangled to prevent dislocation.
  • Prepare the client for, out of bed activity as prescribed.
  • Avoid weight bearing and instruct the client in crutch walking.

Amputation of the lower extremity    

  • It is a surgical removal of a lower limb or part of the limb.

Postoperative Management   

  • Monitor vital signs.
  • Monitor for infection and hemorrhage.
  • Mark bleeding and drainage on the dressing if it occurs.
  • Keep a tourniquet at the bedside.
  • Monitor for pulmonary emboli and necrosis.
  • Observe for and prevent contractures.
  • Evaluate phantom limb sensation and pain.
  • Elevate foot of the bed to reduce edema for 1st 24 hr then flat to prevent hip flexion contraction.
  • After 24 to 48 hr position the client prone if prescribe, to strength the muscle and to prevent flexion contracture of the hip.
  • In the prone position, place a pillow under the abdomen and stamp and keep the legs close together to prevent abduction.
  • Apply Ace wrap or elastic stamp shrinker to provide stamp shrinkage.
  • Remove a rewrap the ace bandage or elastic stump shrinker 3 or 4 times daily for proper shrinkage.
  • Wash the stump with mild soap and water and apply lanolin cream to the skin.
  • Massage the skin toward the suture line to increase circulation.
  • Encourage the client to look at the stamp.
  • Encourage verbalization regarding loss of the body part.
  • Do not allow the stamp to hang over the edge of the bed.
  • Do not allow the client to sit for long periods of time.
  • Instruct the client in crutch walking.
  • Prepare the stamp for prosthesis.


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