Introduction

A fully functioning musculoskeletal system is fundamental to optimal health in the normal active human
being. Injury or disease involving this system can have a profound effect on an individual’s ability to perform
the activities of daily living and can result in either temporary or permanent disability, one of the main
problems usually being the degree of decreased mobility.
This chapter outlines the relevant anatomy and physiology and describes some of the more common
disorders of the musculoskeletal system caused by trauma or disease and the principles of nursing
management and health promotion. The main causes of musculoskeletal trauma or disease in the UK
include road traffic collisions (RTCs), industrial and other work-related accidents, sporting accidents and
damage due to underlying disease such as osteoarthritis or osteoporosis. The overall aim of nursing care
is to prevent further injury, reduce the risk of complications, promote healing, maximise independence and
promote optimal rehabilitation.

Anatomy and physiology of the musculoskeletal system

This section gives a brief overview of the anatomy and physiology of the musculoskeletal system
(see Further reading, e.g. Marieb & Hoehn 2007).

The skeletal system

The skeletal system consists of bones and the joints where they articulate and move.
The main functions of the skeleton are:
• support for the body
• protection for internal organs
• movement – bones and muscles act as levers to produce movement through joints
• mineral storage – minerals such as calcium and phosphorus
• blood cell formation – red bone marrow produces red and white blood cells and platelets.
Structurally, the skeletal system consists of two types of connective tissue: bone and cartilage.

Bone
Bone contains large amounts of calcium which provides its strength. There are two types of bone tissue:
compact and cancellous.
The hard outer layer of a bone is compact bone tissue (cortical bone), while cancellous tissue fills the
inside. Cancellous tissue is spongier in appearance and the larger spaces contain the highly vascular red
bone marrow and the fatty yellow bone marrow. The thickness of each type of tissue varies, depending on
the type and function of the particular bone. In long bones such as the femur, the shaft (diaphysis) is
enclosed by a thick layer of cortical tissue which gives strength for weight-bearing, while at each end, the
epiphyses, the cortical tissue is thinner and encloses a greater mass of cancellous tissue. Bone tissue is
constantly being renewed due to the actions of three types of bone cell: osteoblasts, osteocytes and
osteoclasts. Osteoblasts are involved in bone production, osteoclasts in bone resorption and osteocytes
maintain bone tissue structure.

Cartilage
This is another form of connective tissue; it is tough, flexible, avascular and devoid of nerve fibres. It forms
part of the support mechanism of the body.
There are three types of cartilage:
• hyaline cartilage – firm yet pliable and forms the articular cartilage that covers the articulating surfaces
of synovial joints
• fibrocartilage – strong, compressible and tension-resistant and is found in areas such as the
intervertebral discs
• elastic cartilage – contains more elastin fibres than the others and therefore has a greater ability to
stretch whilst retaining its strength; it is found in the external ear and the epiglottis.

The axial skeletal system

The skull, vertebral (spinal) column and the sternum/ribcage form the central axis of the skeletal system.
The spinal column is a strong, flexible column of 33/34 bones, 24 of which are ‘true’ vertebrae – the 7
cervical (C), 12 thoracic (T) and 5 lumbar (L) vertebrae – the remainder being 9/10 fused bones that form
the sacrum (S) and coccyx (C) (Figure 10.1). Between each of the vertebrae from C2 to S1is a strong
joint created by the fibrocartilaginous intervertebral discs, which allow flexibility and act as shock absorbers
when the spine is exposed to vertical forces.

Figure 10.1 The vertebral (spinal) column – lateral view.

The vertebral (spinal) column functions to protect the spinal cord, to support the skull and to act as a
point of attachment for the ribs and muscles of the back.

The appendicular skeletal system

The bones of the upper and lower limbs and their girdles (the upper pectoral girdle and the lower pelvic
girdle) are the main parts of the appendicular skeletal system. They are characterised by the presence of
synovial joints which connect the articular surfaces of adjoining bones ( Figure 10.2). The bones that
make up the joint are held within a fibrous capsule, which consists of two layers:
• an outer layer of dense connective tissue which allows movement but resists dislocation
• an inner layer lined with synovial membrane which secretes synovial fluid; this provides nourishment
and lubrication.

Figure 10.2 A synovial joint – the knee joint. A. Section viewed from front. B. Section viewed from side. C. Superior
surface of the tibia showing the semilunar cartilages and cruciate ligaments.

The articular surfaces of the bones involved are covered in hyaline cartilage – articular cartilage.

Ligaments
Ligaments attach bone to bone and are vital in maintaining the stability of a joint. They are made of dense
connective tissue and have a relatively poor blood supply. A joint may have many ligaments, such as the
knee which has the cruciate ligaments to prevent the femur and tibia moving forwards on each other and
the medial and lateral collateral ligaments which prevent side to side movement ( Figure 10.2). Damage
to ligaments can result in an unstable and painful joint, common in football injuries.

The muscular system

Skeletal muscle (voluntary or striated muscle) tissue is composed of multinucleated muscle cells which are
long and cylindrical in appearance. Each muscle is made up of muscle fibres and connective tissue. A good
blood and nerve supply is essential for muscle function and the mechanics of movement.

Tendons
Tendons attach muscle to bone and allow movement of joints to take place. As with ligaments, tendons
have a relatively poor blood supply. Damage to tendons can therefore be as serious as bony injury and
prevent movement in an individual.
Nursing management and health promotion: general principles of musculoskeletal disorders
Nursing assessment
This will involve a holistic assessment of the patient, as musculoskeletal disorders can have profound
effects on a patient physically, psychologically and socially. In addition, visual inspection, palpation,
measurement, and other investigations such as radiological/imaging studies ( Box 10.1) and blood tests
in rheumatoid arthritis, for example, are necessary.
Box 10.1 Information

Investigations for musculoskeletal abnormalities

Radiological and imaging studies

• Radiograph (X-ray) – to detect abnormal position, fractures, arthritis and presence of fluid or abnormalities in joint
capsules.
• Computed tomography scan (CT scan) – makes use of the fact that different tissues have varying radiodensities. A
series of radiographs are made at different angles and planes and the computer integrates the information to produce
pictorial slices (sometimes 3D) which can be used to detect soft tissue injuries or tumours and inflammatory or
metastatic skeletal disease or fracture.
• Magnetic resonance imaging (MRI) – magnetic fields are used to show the difference in hydrogen density of various
muscle and soft tissues, indicating the presence of abnormalities especially of the back and knee.
• Dual energy X-ray absorptiometry (DEXA) scan – scan for bone density, e.g. to detect osteoporosis.

Joint examination
• Arthroscopy – endoscopic visualisation of structures inside a joint undertaken under general or spinal anaesthetic.
May also involve withdrawal of synovial fluid for analysis, and treatments such as washout of the joint to remove
debris or the trimming of any damaged structures, e.g. the menisci in the knee joint.

Muscle and nerve studies

• Electromyography (EMG) – measures electrical potential of muscle during rest and activity.
• Nerve conduction velocities (NCVs) – measure speed of nerve impulse conduction.

Other tests
• These include bone biopsy, total body calcium and various blood tests (biochemical haematological studies) that
include full blood count (FBC), erythrocyte sedimentation rate (ESR), rheumatoid factor, C-reactive protein (CRP),
hormone and mineral levels, blood culture, etc.

In particular the nurse should assess for:

• the patient’s perception of the cause of the primary problem
• the patient’s knowledge and understanding of the condition
• the patient’s description of pain and other symptoms
• abnormal position or appearance of limbs or affected part, with loss of function (compare with
contralateral side)
• abnormal posture or gait
• use of walking aids or prostheses
• concurrent health problems, allergies and medications
• the impact on activities of living (ALs), especially relating to impaired mobility (see Further reading,
e.g. Holland et al 2008)
• the patient’s and the family’s expectations and coping strategies.
Problems and strengths (actual and potential) are identified in the following categories:
• life-threatening problems such as shock
• pain
• impaired mobility
• knowledge deficit
• potential for further injury – physical safety and neurovascular complications, especially compartment
syndrome, venous thromboembolism (VTE) and fat embolus (see below and p. 341)
• psychosocial consequences
• patient and family strengths – these should be defined and used constructively
• rehabilitation.

Nursing interventions
These will include:
• Treat life-threatening problems – ABC of resuscitation (see Chs 2, 27). Ensure early recognition of and
treatment of shock (see Ch. 18).
• Relieve pain.
• Maintain an appropriate degree of therapeutic restriction and mobility.
• Constantly monitor and reduce the risk of neurovascular complications such as compartment syndrome
and VTE.
• Maintain a safe environment.
• Explore the patient’s and family’s understanding of the condition and provide support and education
based on individual needs.
• Coordinate multidisciplinary intervention for psychosocial problems.
• Facilitate rehabilitation.
Nursing management and health promotion: core potential complications
The three potential complications – compartment syndrome, VTE and fat embolus – are common to
many musculoskeletal injuries and can also occur after orthopaedic surgery. They are thus to be considered
when caring for patients with any acute musculoskeletal injury or condition.

Compartment syndrome (CS)

Compartments within the body are areas where muscle, nerve and blood vessels are confined within
inelastic boundaries of skin, fascia and/or bone. Compartment syndrome occurs when there is increased
tissue pressure resulting in compromised circulation and function of tissues within a compartment ( Lucas
& Davis 2004). This results in tissue death (necrosis) and permanent loss of function, which can occur
within 6–8 h. Increased pressure can result from direct trauma to the area, surgery or the application of a
cast or other immobilisation aid. Nursing observations include examination of the colour, warmth, sensation
and movement (CWSM) of the foot or hand distal to the injury, surgery site or constricting device such as
a cast. The ‘5 Ps’ that should be looked for are:
• pain (out of proportion to the injury and despite analgesia)
• paraesthesia – altered sensation such as ‘pins and needles’ or numbness
• paralysis
• pallor
• pulselessness (a late sign).
In order to reduce the risk of CS developing the affected limb should be elevated, unless CS is
suspected to have occurred, when elevation can exacerbate the condition and should be stopped ( Lucas
& Davis 2004). Compartment syndrome is an orthopaedic emergency and patients need to have surgery
to relieve the pressure – a fasciotomy where the inelastic tissue surrounding the compartment is cut open.

Venous thromboembolism
Venous thromboembolism is a collective name for two conditions: deep vein thrombosis (DVT) and
pulmonary embolism (PE). The risk factors for DVT are:
• venous stasis, such as when patients have reduced mobility after musculoskeletal trauma or surgery
• damage to veins after trauma
• hypercoagulability of the blood after injury.
It is usually a combination of these factors that causes a DVT. The result is a clot in the deep veins
(of the leg or pelvis), most commonly of the lower leg. Signs and symptoms may include pain/tenderness,
calf pain when the foot is dorsiflexed, redness, heat, swelling and hardness of the affected areas.
Sometimes, however, there are no physical signs. Nursing management and health promotion includes
educating vulnerable patients about the signs and symptoms so that they can inform staff if they occur, and
the use of preventative measures to reduce the risk (see Ch. 26). These measures may be
pharmacological, for example low molecular weight heparin injections, or non-pharmacological such as
properly fitted antiembolism stockings, foot impulse device and early mobilisation (National
Collaborating Centre for Acute Care 2007).
A DVT which breaks off and travels through the heart to the pulmonary circulation is known as a PE.
This is an emergency as it can lead to respiratory arrest and death. The clinical presentation depends on
severity but includes sudden sharp chest pain, tachycardia, dyspnoea, cough, cyanosis, fainting,
sometimes haemoptysis, and restlessness/confusion in previously orientated patients. There will also be
characteristic electrocardiogram changes. (See Further reading, e.g. Farley et al 2009, for details of
PE.)

Fat embolus
Fat emboli can occur following fracture of any long bone or after orthopaedic surgery where a long bone is
cut, such as a joint replacement. There are two theories relating to the cause: one is that fat cells from
damaged tissue migrate into ruptured veins; the other is that catecholamines released through the stress
of trauma mobilise lipids from fatty tissue. In the lung, these droplets are converted into free fatty acids
which are toxic to lung tissue and disrupt alveolar function. Additionally, the droplets may become
enmeshed in the capillary network of the alveoli and disrupt gas exchange. This can lead to cerebral hypoxia
and, if large vessels in the pulmonary system are involved, to respiratory failure and death. Early signs of
fat emboli are increased respiratory rate, anxiety, confusion, and transient petechial haemorrhage (tiny
broken capillary blood vessels) on the head, neck and face.
The nurse must be alert for early signs of altered mental status – anxiety, irritability and especially
confusion. Report this immediately and be prepared to deal with respiratory failure and arrest and to transfer
the patient to intensive care. Equipment should be ready for immediate blood gas analysis.

Skeletal disorders

This section of the chapter outlines a range of skeletal injuries and conditions, including fractures, spinal
injury, osteoporosis, tumours and infections.

Fractures
A fracture or ‘broken bone’ is a break in the continuity of a bone (Langstaff 2000) as a result of direct or
indirect trauma, underlying disease (pathological fracture) or repeated stress on a bone (stress fracture). It
is described as a closed fracture when there is no communication between the external environment and
the fracture site, and open when communication occurs. Stable fractures are those where the bone ends
are lying in a position from which they are unlikely to move. In unstable fractures the bone ends are
displaced or have the potential to be displaced. The edges of the broken bones may damage soft tissues
or blood vessels/nerves at the time of the injury or later through poor handling of the limb.

Medical/surgical management
All fractures, regardless of their position or the size of the bone involved, are managed according to three
principles: reduction, maintenance of position and rehabilitation. The aim is to allow bone healing to take
place. The stages of bone healing are demonstrated in Figure 10.3.

Figure 10.3 Stages in bone healing.

Reduction of fractures
Fractures are said to be reduced when displaced bone fragments are pulled into their normal anatomical
position. In many cases, a general anaesthetic will be necessary to overcome the protective muscle spasm
and severe pain.

Maintenance of position
The fracture needs to be held in the correct position until bony healing takes place, which can take from 6
to 12 weeks depending on the fracture site. Position can be maintained by external splintage using an
orthosis, i.e. a removable splint, plaster of Paris (POP) or synthetic (resin/plastic based) casts, skin or
skeletal traction, or an external fixator frame. Operative reduction with internal fixation by metal pins, plates,
screws or nails may also be used to hold the bony fragments in position. When the blood supply is grossly
affected, it may be necessary to implant a prosthesis to replace the affected bone, e.g. in some cases of
fractured neck of femur. Without adequate maintenance of position the fracture may heal with the bone
ends not properly aligned (malunion), take longer to heal (delayed union) or not unite at all (non-union).

Restoration of function
Joints and muscles near to the fracture can become stiff and weak and physiotherapy and exercise is
essential.
Patients require varying degrees of rehabilitation, involving a multidisciplinary team approach
(see Ch. 32). It should be remembered that even when the physical damage is slight, the psychosocial
impact may be considerable.

Traction
Orthopaedic traction occurs when a pulling force is applied to a part or parts of the body, and counter-
traction, a pulling force in the opposite direction, is also applied ( Lucas & Davis 2004). Counter-traction
is usually supplied by the body weight of the patient. It is used in the following circumstances:
• to reduce and immobilise fractures/dislocations and maintain normal alignment of all injured tissues
• to prevent and correct deformity
• to reduce muscle spasm
• to relieve pain
• to immobilise an injured or inflamed joint
• to keep joint surfaces apart.
Traction is less used than in the past as alternative methods, in particular internal fixation, enable
patients to become mobile more quickly and therefore avoid the problems of bed rest. However, it still has
its place in treatment and nurses must know the principles of its use.

Types of traction

Balanced or sliding traction

This relies on the patient’s own body weight to produce the necessary counter-traction, usually by tilting of
the bed. Skeletal pins may be used to provide a firm point of attachment ( Figure 10.4), but the most
common type of balanced traction uses skin traction. This is Buck’s traction which is used as a temporary
measure for pain relief in patients with a fractured neck of femur ( Figure 10.5). However, a Cochrane
Review (Parker & Handoll 2006) could find no evidence which conclusively demonstrated the benefit
of such traction for the outcome measures of pain relief or ease of fracture reduction at the time of surgery
and its use has been discontinued in many orthopaedic centres.

Figure 10.4 Skeletal traction may be applied by: A, a Kirschner wire and traction stirrup; B, a Steinmann pin and
traction stirrup; or C, a Steinmann pin and Böhler stirrup.
Figure 10.5 Buck’s traction for femoral neck fractures.

Fixed traction
This is the application of counter-traction acting through an appliance which obtains purchase on a part of
the body (Figure 10.6). The most common is a Thomas’ splint, used for restricting movement of a
fractured shaft of femur when transferring a patient, e.g. between hospitals, or in the treatment of fractures
of the shaft of femur in children (Lucas & Davis 2004).

Figure 10.6 A. Fixed traction using skin traction and Thomas’ splint. B. Fixed traction using skeletal pin and Thomas’
splint.

Nursing management and health promotion: traction

In addition to the general principles outlined earlier for management of musculoskeletal disorders (p.
339), the following are specific to a patient in traction.

Health promotion
Patients need to understand the reasons for their traction and how to move safely within the bed.

Management of equipment
All parts of frames, pulleys, ropes and slings should be inspected at regular intervals every day to ensure
that they are correctly positioned and in good working order; this is especially important when the patient
has been moved, e.g. after using a bedpan.

Reducing the risk of complications

• Observation of colour, warmth, sensation and movement (CWSM) of the injured limb must be carried
out throughout the patient’s stay in hospital for early detection of compartment syndrome ( Lucas &
Davis 2004).
• Potential skin breakdown around the traction and in vulnerable areas such as the sacrum should be
monitored and appropriate pressure-relieving devices used.
• Observe for drop foot caused by excessive pressure on the common peroneal nerve located around the
head of the fibula.
• Work with the physiotherapists to ensure that patients are aware of the importance of deep breathing
exercises and exercise of limbs to prevent chest infection, DVT and muscle wasting.

Care of skeletal pin sites

A Cochrane Review (Lethaby et al 2008) concluded that there is little evidence as to which pin site care
regimen best reduces infection rates but there are best practice guidelines available based on the available
literature and expert opinion (Lee-Smith et al 2001). These indicate that:
• Pin sites do not need to be cleaned if there is no exudate present. However, when necessary, cleaning
should be done using 0.9% saline
• Pin site crusts should be removed as this allows visualisation of the wound and free drainage of exudate
• Pin sites may be left exposed if there is no exudate, otherwise woven gauze should be used.
Purulent discharge, redness or inflammation suggests infection and a wound swab should be taken
to identify the causative organisms. The appropriate antibiotics should be commenced and the pin sites
cleaned with 0.9% saline and dressed with woven gauze, changed as necessary ( Lee-Smith et al 2001).
Fundamental aspects of care
Patients on traction have limited mobility and may be on bed rest for 6 weeks or more. Fundamental nursing
issues to consider are:
• maintaining adequate fluid and dietary intake to prevent constipation and urinary tract infection
• maintaining patient dignity when meeting patient hygiene and toileting needs
• helping patients to maintain their contact with partners, family and friends, providing privacy as required
• helping patients to find ways of alleviating the boredom of prolonged bed rest ( Box 10.2).
Box 10.2 Reflection

Dealing with boredom

Harry may be on bed rest for many weeks whilst on traction. He is worried about the long period of immobility and not
being able to attend his university course or continue with his active social life.

Activity
• Think about times when you were bored and reflect on having to be on traction for weeks.
• Discuss with your mentor ways in which you can help Harry to relieve the boredom.
• Which other health professionals and other people could you call upon to help in this respect?

Casts
A cast is a splinting device comprising layers of bandages impregnated with POP, fibreglass or resin, some
of which are applied wet and solidify as they dry out. Their main uses areto immobilise and hold bone
fragments in reduction and to support and stabilise weak joints. POP moulds more easily but it takes 48 h
to dry and it is heavy. Synthetic casts set within 20 min and allow early weight-bearing but do not
accommodate swelling and are not usually used in the initial stages of treatment, when a POP backslab is
used. Other types of casts include adjustable focused rigidity primary casts which can be adjusted as
swelling reduces (Large 2001) and cast braces which have hinges at the joints to allow restricted amounts
of flexion or bend to stimulate cartilage nutrition (Dandy & Edwards 2009).
Nursing management and health promotion: casts
In addition to the general principles of nursing management for musculoskeletal disorders ( p. 339),
the following will also apply.

Care of the cast

POP casts should be handled carefully when drying, using the palms of the hands rather than the fingers
to prevent indentations which may cause pressure points. Patients should understand that a cast should
not get wet and that synthetic protective covers can be used to permit them to take a shower. Patients
should be taught how to protect the cast when washing and when using bedpans and urinals.
Many patients will go home wearing casts and need clear verbal and written instructions specific to
their cast (Box 10.3 outlines advice for a patient with a hand to elbow plaster).
Box 10.3 Information

Advice to a patient with a hand to elbow plaster

The plaster holds all the broken bones firmly in place to allow them to heal in the correct position. To prevent your
fingers swelling, support your arm in the sling provided during the day and on pillows at night. It is important that you
exercise the finger, elbow and shoulder joints of your injured arm at regular intervals, otherwise they will become stiff
and painful to move.
The following exercises should be carried out at least four times each day:
• Make a firm fist then stretch the fingers as wide as possible.
• Try to touch each fingertip with the thumb of that hand.
• Bend and stretch the elbow joint.
• Lift your arm high above your head – use the other arm to help.
• Move your arm behind your back as if you wanted to scratch between your shoulder blades.
Do not wet, heat or otherwise interfere with the plaster and do not insert sharp objects between the plaster and
the skin to scratch – this could cause skin damage and infection.
Report to the doctor or Emergency Department AT ONCE if:
• The plaster cracks, becomes loose or uncomfortable.
• There is pain.
• The fingers become numb or difficult to move.
• The fingers become more swollen, blue or very pale.
• There is discharge.
• You have any other problems.

Potential for neurovascular impairment

Swelling or a too tight cast may lead to neurovascular impairment such as CS. CWSM observations should
be carried out for early identification of problems. If CS or neurovascular impairment is suspected the cast
needs to be split or bivalved down to the skin. If a local pressure ulcer develops beneath a cast, usually
identifiable by specifically located pain, an inspection window can be cut and the ulcer dressed before the
window is taped or bandaged back into place.

Removal of a cast
Removal of a cast is a skilled activity and should only be carried out by nurses who have been deemed
competent in this role. Removal can be achieved using plaster shears for POPs or an electric oscillating
saw for POPs and synthetic casts.

External fixation
Bone fragments are held in position by skeletal pins inserted into the bone on either side of the fracture and
held in alignment by a scaffold or a ring fixator ( Figure 10.7). They are used for the treatment of some
closed fractures, e.g. the pelvis, to stabilise open fractures with extensive soft tissue loss until the soft tissue
has healed, for fractures that have not united by other methods, and for reconstructive surgery such as leg
lengthening. Depending on the reason for their use they can be in place for as little as 6 weeks, e.g. for
treatment of a closed fracture, or up to 1 year, e.g. in non-union of a tibial fracture.

Figure 10.7 An example of external fixation – Ilizarov frame.

(Courtesy of Barts and the London NHS Trust.)

Nursing management and health promotion: external fixation

The general principles relating to potential neurovascular impairment, positioning and potential for pin
site infection that have already been discussed are important in the care of patients with an external fixator.
In addition it is important that the patient, carers and community staff are confident in caring for the external
fixator when the patient is discharged from hospital, including managing issues related to altered body
image (Limb 2004). (See Further reading, e.g. Dandy & Edwards 2009.)

Internal fixation
Fractures may also be stabilised by surgical intervention where nails, plates, wires, screws or rods hold the
bone fragments in place (Figure 10.8). Again this permits earlier mobilisation and reduces the potential
for complications. The general principles of nursing management and health promotion of musculoskeletal
disorders and of core potential complications (pp. 339–341) apply. In addition the perioperative principles
of nursing management are also relevant (see Ch. 26).
Figure 10.8 Types of internal fixation. A, B. Intramedullary nails. C. Compression nail for fixation of femoral neck. D.
Sliding nail fixation of the femoral neck.

Fractures of specific sites – lower limb

Any of the bones in the lower limb can be fractured due to trauma, and the principles of reduction,
maintenance of position and restoration of function apply to all. The specific treatment and associated
nursing care and health promotion depend on the exact nature of the fracture and the patient involved. Two
of the commonest fractures are those of the femoral neck and the tibia/fibula, and these are discussed in
more detail.

Fracture of neck of femur

There are approximately 70 000 fractures of the femoral neck, commonly known as a hip fracture or
fractured neck of femur (and abbreviated as #NOF), in the UK each year ( British Orthopaedic
Association [BOA] 2007). They are most common in older people, particularly women who may have
osteoporosis. There is much evidence that a coordinated approach to care of this patient group can improve
patient outcomes (Box 10.4).
Box 10.4 Evidence-based practice

Hip fracture: the care of patients with fragility fracture: the ‘Blue Book’ guidelines

The British Orthopaedic Association and the British Geriatrics Society, together with other organisations including the
Royal College of Nursing, has examined the evidence for the care of patients with a hip fracture and published good
practice guidelines. The six standards are:
1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation.
2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during
normal working hours.
3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a
pressure ulcer.
4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to
acute orthogeriatric medical support from the time of admission.
5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy
to prevent future osteoporotic fractures.
6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and
intervention to prevent future falls.
(The British Orthopaedic Association, 2007.)

Activities
• Access Care of Patients with Fragility Fractures at www.nhfd.co.uk and identify which team members it considers to
be essential for the multidisciplinary care of patients with a hip fracture.
• What is the role of the ‘Hip Fracture’ nurse specialist, according to the document?

Medical/surgical management

History and examination

The patient will complain of severe pain in the hip or knee and there may be visible shortening and external
rotation of the affected leg. Diagnosis will be confirmed by X-ray. A history of the fall is important as it may
identify underlying conditions such as hypotension and indicate how long the patient may have been lying
on the floor before receiving help.

Treatment
Depending on the site of the fracture, and the age and condition of the patient, the treatment will be either
internal fixation with a plate and screws or replacement of the head of femur with a metal prosthesis if the
fracture is inside the joint capsule and there is a risk of damage to the blood supply of the femoral head
(Figure 10.9). The underlying osteoporosis needs to be treated (see p. 351).

Figure 10.9 Blood supply of the femoral head via the capsule, intramedullary vessels and ligamentum teres.

Nursing management and health promotion: fracture of neck of femur

In addition to the general principles relating to musculoskeletal injury and fractures, the following
priorities need to be addressed.

Potential complications
As a result of age and general physical condition when found, the patient may be confused and fearful and
need a great deal of comfort and reassurance. Measureswill be taken to reverse any hypothermia and
dehydration (see Chs 20, 22). Risk assessment of the patient for skin breakdown using an approved
scale such as the Waterlow scale (see Ch. 23) should be recorded and the patient may be nursed on a
therapeutic bed. Vital signs will be monitored at least 4-hourly intervals to detect early signs of
complications.

Pain
With an extracapsular fracture there is often extensive bruising which adds to the severe pain. Pain
assessment and pain relief measures should be implemented (see Ch. 19) including repositioning and
supporting the limb, and administering prescribed analgesics.

Increased risk of multisystem complications

For an older patient, such acute trauma and associated surgery may lead to multisystem failure (see Ch.
18).

Rehabilitation

Discharge planning should commence within 48 h of admission ( Scottish Intercollegiate Guidelines

Network [SIGN] 2002). The use of an integrated care pathway (ICP) can help to improve the standard
of overall care by ensuring that each member of the multidisciplinary team knows the best available
evidence for care and when that care should be carried out ( Tarling et al 2002) (Table 10.1, Box
10.5). Early supported discharge schemes, often led by nurses, can help to ensure that patients are
discharged rapidly but safely to their home environment ( British Orthopaedic Association 2007).
Table 10.1 Extract from the integrated care pathway of a patient with a fractured neck of femur – postoperative day 1
(nursing part only)

Patient
Nursing Intervention Expected Outcome
Problem/Need

Recovery from At least 4-hourly monitoring of vital Vital signs within patient’s
anaesthetic signs normal limits
 Wound care Check wound site dressingCheck and Dressing dry and
record wound drainage intactDrain to be removed at
24 h after surgery as further
drainage minimal

Neurovascular Monitor neurovascular status of No neurovascular deficit

status of limb affected limb

Relief of pain Use pain score with patient at least 4- Pain relief at level
hourlyAdminister analgesics as acceptable to patient
prescribed

Risk of deep vein Ensure antiembolism stocking in Reduction in risk and early
thrombosis (DVT) situThromboprophylaxis injection as detection of problem
prescribedMonitor for signs of DVT

Reduced mobility Ensure patient understands correct way Patient to sit in chair Patient
to transfer and mobilise to walk to end of bed with
aid of Zimmer frame

Box 10.5 Reflection

Integrated care pathways (ICP)

An ICP is different from traditional medical and nursing notes in many ways.

Activities
• Think about the material in Table 10.1, Tarling et al (2002) and, if possible, an ICP in use in your placement.
• Discuss with your mentor the differences between ‘traditional’ medical and nursing notes and ICPs and the relative
advantages and disadvantages of each.

Fracture of the tibia and fibula

Fracture of the tibia and fibula is one of the most common injuries dealt with by orthopaedic surgeons.
These fractures usually result from direct impact to the limb, and extensive skin and soft tissue damage
may be present. RTCs and sports injuries are common causes.