NCLEX-RN® Musculoskeletal Disorders: Fractures, Traction, Cast Care, Amputation, and Osteoporosis

Musculoskeletal nursing for the NCLEX-RN®: compartment syndrome assessment, traction principles, cast care teaching, post-amputation positioning, and osteoporosis fall prevention.

The big picture

Musculoskeletal questions on the NCLEX-RN® test your ability to recognize neurovascular compromise, manage traction and casts safely, prevent complications of immobility, and teach patients about bone health. The priority in almost every musculoskeletal scenario is checking circulation, sensation, and movement (CSM) — a deficit signals an emergency.

Fractures

A fracture is a break in bone continuity. NCLEX® tests fracture types, priority assessment, and complication recognition — not surgical technique.

Fracture types to know

Fracture assessment: the 6 Ps of neurovascular compromise

Assess the limb distal to the injury or cast:

1. Pain — especially unrelieved by position or analgesics
2. Pulse — compare to opposite extremity; absence = vascular emergency
3. Pallor — skin color change indicating poor perfusion
4. Paresthesia — numbness, tingling (early nerve compression)
5. Paralysis — inability to move (late; serious)
6. Poikilothermia (Polar) — limb feels cold

NCLEX® alert: Report any of the 6 Ps immediately — they indicate compartment syndrome, vascular injury, or nerve damage. Paresthesia is the earliest and most reliable sign of nerve compromise.

Fat embolism syndrome (FES)

Fat embolism occurs when fat particles from fractured bone (especially long bones like the femur) enter the bloodstream. Most common 24–72 hours post-fracture or post-surgery.

Classic triad:

1. Respiratory distress (hypoxia, tachypnea) — most prominent; resembles ARDS
2. Petechiae — over the chest, axillae, conjunctivae — pathognomonic
3. Neurological changes — confusion, restlessness

Priority action: Notify provider immediately. Administer oxygen. Prepare for possible intubation. Fat embolism has no antidote — management is supportive.

Compartment syndrome

Compartment syndrome is a surgical emergency — bleeding or edema inside a fascial compartment raises pressure, compressing blood vessels and nerves.

Causes: Tight casts, circumferential burns, crush injuries, reperfusion after vascular repair.

Defining sign on NCLEX®: Pain out of proportion to the injury that is not relieved by opioids — especially pain on passive stretch of the muscles in that compartment.

Pressure threshold: > 30 mmHg (or within 30 mmHg of diastolic BP) = fasciotomy required.

Nursing actions:

1. Remove constrictive dressings, loosen or bivalve cast — can be done by the nurse for a cast
2. Keep extremity at heart level (not elevated — elevation reduces perfusion pressure)
3. Notify provider immediately — fasciotomy may be urgent
4. Never apply ice or heat

Traction

Traction applies a pulling force to align bone or relieve muscle spasm.

Types of traction

Skeletal traction nursing care

• Pin site care: Clean per facility protocol (saline or antimicrobial solution); assess for redness, drainage, crusting, loosening — signs of infection
• Maintain continuous pull: Weights must hang freely — never rest on the floor or bed; never remove weights unless ordered
• Maintain alignment: Keep patient in prescribed position; do not remove traction to reposition unless ordered
• Countertraction: The patient's own body weight provides countertraction — ensure head of bed position is correct for the type of traction ordered
• Bowel and bladder care: Constipation is common; offer bedpan and privacy; encourage fluids and fiber

Cast care

Casts immobilize fractures during healing. NCLEX® tests complications and teaching.

Wet cast care

• A fresh plaster cast takes 24–72 hours to dry; fiberglass casts dry faster (30–60 minutes)
• Handle with palms (not fingertips) to prevent indentation pressure points while wet
• Keep exposed (do not cover) and elevate to reduce swelling

Cast care teaching

Petaling a cast edge

Rough cast edges can cause pressure sores. Apply petal-shaped moleskin over the edges, folding each piece inside and outside to create a smooth border.

Amputations

Amputations are performed for vascular disease, trauma, infection, or cancer. NCLEX® focuses on post-op care and rehabilitation.

Immediate post-amputation priorities

1. Hemorrhage monitoring: Keep a tourniquet at the bedside (not on the patient); if bleeding occurs, apply direct pressure; tourniquet only as a last resort
2. Elevate stump for first 24 hours to reduce edema — after 24 hours, do NOT elevate (hip flexion contracture risk for lower extremity amputation)
3. Stump wrapping: Figure-8 bandage promotes shrinkage and shapes the residual limb for prosthesis — rewrap every 4–8 hours or when loose
4. Phantom limb pain: Real pain — neurological phenomenon, not psychological. Treat with: mirror therapy, gabapentin, tricyclic antidepressants, nerve blocks.

Preventing contractures

For below-knee amputation: avoid pillow under knee (promotes flexion contracture). For above-knee: avoid pillow under stump; position prone for 30 minutes 3–4 times daily if possible.

Osteoporosis

Osteoporosis is decreased bone density leading to fragile bones and fracture risk. The most clinically dangerous fractures are hip and vertebral fractures.

Risk factors

• Female sex (estrogen loss at menopause)
• Older age
• Small frame, low body weight
• Calcium and vitamin D deficiency
• Inactivity/immobility
• Smoking, excessive alcohol
• Long-term corticosteroid use (most common iatrogenic cause)
• Family history

Diagnosis

DEXA scan (dual-energy X-ray absorptiometry) measures bone density:

• T-score > -1.0: Normal
• T-score -1.0 to -2.5: Osteopenia
• T-score < -2.5: Osteoporosis

Treatment and teaching

NCLEX® clinical judgment focus

The single most important assessment for any musculoskeletal patient: Neurovascular status (CSM) distal to the injury, cast, or traction.

Priority escalation:

• Absent pulse distal to fracture → vascular emergency, notify provider immediately
• Paresthesia or paralysis → compartment syndrome until proven otherwise
• Sudden respiratory distress + petechiae 24–72 h after long bone fracture → fat embolism
• Hemorrhage from amputation stump → direct pressure first; tourniquet as last resort

Common NCLEX® traps:

• Elevating an amputated stump beyond 24 hours — causes contracture
• Resting weights on the floor during traction — removes the therapeutic pull
• Telling the patient phantom limb pain is "in their head" — this is real, neurologically mediated pain
• Forgetting to teach bisphosphonate patients to stay upright for 30–60 minutes

FAQ

What is the most common cause of compartment syndrome?

Compartment syndrome most commonly occurs after fractures (especially tibial and forearm fractures) and can also be caused by tight casts, circumferential burns, and crush injuries. The hallmark is pain out of proportion to the injury that is not relieved by analgesics.

How is fat embolism syndrome different from pulmonary embolism?

Both cause respiratory distress, but fat embolism has two additional distinguishing features: petechiae (small pinpoint hemorrhages over the chest, axillae, and conjunctivae) and neurological changes (confusion, agitation). It occurs 24–72 hours post-fracture of a long bone, while a PE typically occurs 3–5 days post-op. FE has no antidote; PE is treated with anticoagulation.

How should a bisphosphonate be taken correctly?

Take alendronate (Fosamax) first thing in the morning on an empty stomach with a full glass (8 oz) of plain water. Do not eat, drink, or take other medications for at least 30 minutes. Stay upright (sitting or standing) for 30–60 minutes after — lying down allows the drug to reflux into the esophagus and cause severe erosive esophagitis.

Why is phantom limb pain not psychological?

Phantom limb pain is caused by reorganization of sensory pathways in the brain after the amputation. The somatosensory cortex that processed signals from the limb is still active and generates pain signals. It is a legitimate neurological phenomenon, not a psychological one, and requires real pharmacological and non-pharmacological treatment.

What type of exercise is best for osteoporosis?

Weight-bearing exercise — activities where you carry your body weight against gravity. This includes walking, jogging, dancing, and resistance training. Swimming and cycling are excellent cardiovascular exercises but are NOT weight-bearing and do not build bone density. Both types should be part of an overall health plan.

Key takeaways

• Fractures: Assess the 6 Ps of neurovascular status. Paresthesia = earliest sign of nerve compromise. Open fracture = infection risk.
• Compartment syndrome: Pain out of proportion + pain on passive stretch = emergency. Remove constrictive dressing; fasciotomy if pressure > 30 mmHg.
• Traction: Weights hang freely at all times. Skeletal pin sites: assess for infection. Countertraction = patient's own body weight.
• Casts: Elevate first 24–48 hours. Report the 6 Ps. Never scratch inside cast. Report foul odor.
• Amputations: Tourniquet at bedside. Elevate first 24 h only. Stump wrapping promotes prosthesis fit. Phantom pain is real.
• Osteoporosis: DEXA scan. Weight-bearing exercise. Bisphosphonates: empty stomach, stay upright 30–60 min. Calcium in divided doses.

Sources: NCSBN NCLEX-RN® 2023 Test Plan; National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS); U.S. National Library of Medicine MedlinePlus — Bone, Joint and Muscle.

See also:

• Mobility and Immobility: Complications of Bedrest
• NCLEX-RN® Integumentary and Burns
• NCLEX-RN® Patient Safety Guide
• NCLEX-RN® Pharmacology Guide (Pain Management)
• Perioperative Nursing Guide

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