Musculoskeletal Disorders: Fractures, Arthritis, Amputation, and Mobility

Objective. Students will demonstrate safe patient mobility techniques including positioning, transfer, and assistive device use, and describe nursing care for patients with fractures, hip replacement, rheumatoid arthritis, and lower-limb amputation.

Musculoskeletal Disorders: Fractures, Arthritis, Amputation, and Mobility

Musculoskeletal conditions are among the most common reasons adults require nursing care. As an LPN, you will assist patients with fractures, joint replacement, arthritis, and amputation—all of which affect mobility and independence. Your role centers on safe patient handling, preventing complications, and supporting recovery.

Fractures and Hip Replacement

A fracture is a break in bone continuity. Hip fractures are especially significant in older adults, often resulting from falls combined with osteoporosis. Surgical repair—either open reduction internal fixation (ORIF) or total hip replacement (arthroplasty)—is common. After hip replacement, the patient must follow hip precautions to prevent prosthetic dislocation:

Do not flex the hip beyond 90 degrees.
Do not allow the operative leg to cross the midline (adduction).
Do not internally rotate the operative leg.

Remember these as "No bend, no cross, no twist." Always position the patient with an abduction pillow between the legs when in bed. When transferring, move the operative leg as a unit, keeping these limits in mind. Notify the registered nurse (RN) or provider immediately if the patient reports sudden hip pain, a "pop," or if the leg appears shortened and externally rotated—signs of dislocation.

Nursing care for fractures also includes neurovascular assessment: check the five P's distal to any fracture or cast—Pain, Pallor, Pulse, Paresthesia, and Paralysis. Impaired circulation or nerve compression is a medical emergency.

Safe Patient Handling Techniques

Injury to patients and nurses is preventable with correct technique. Never lift a patient manually when an assistive device or additional staff is available.

Log-rolling keeps the spine in alignment during repositioning. It requires at least two caregivers. One person stabilizes the head and neck; the second places hands at the shoulder and hip. On a coordinated count, both roll the patient as a single unit. This is essential after spinal surgery or spinal injury.

Repositioning in bed with a draw sheet reduces shear and friction. A draw sheet (or slide sheet) is placed under the patient from shoulders to hips. Two nurses stand on opposite sides of the bed, grasp the sheet at shoulder and hip level, and move the patient together on a count. Always lower the bed to a flat or slight Trendelenburg position to reduce effort.

Two-person transfer to a chair for a post-hip-replacement patient requires a transfer belt applied snugly around the patient's waist. The patient moves to the edge of the bed by pivoting on the non-operative leg, keeping the operative leg extended. Staff support both sides. The patient reaches back for the armrest before sitting—never bending forward past 90 degrees at the hip.

Assistive Device Use

Walker: Provides maximum stability. The patient lifts or rolls the walker forward, then steps into it—weak or operative leg first, then the stronger leg. The walker height is correct when elbows are flexed about 15–30 degrees with hands on grips.

Axillary crutches (non-weight-bearing gait): Weight is borne through the hands, NOT the axilla—axillary pressure can compress the brachial plexus ("crutch palsy"). In a three-point non-weight-bearing gait, both crutches advance together, then the non-operative leg swings forward; the operative foot does not touch the ground.

Cane: Used on the side opposite the weak extremity to broaden the base of support. The patient moves the cane forward with the weak leg simultaneously, then advances the strong leg.

Always verify proper fit and inspect rubber tips for wear before any patient uses an assistive device.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic autoimmune inflammatory disease affecting synovial joints bilaterally and symmetrically. Key nursing concerns include:

Morning stiffness lasting more than one hour is characteristic.
Apply warm or cool compresses as ordered to reduce joint pain.
Encourage active range-of-motion exercises during remission; rest inflamed joints during flares.
Teach joint protection: avoid tight gripping, use assistive devices for daily tasks.
Monitor for drug side effects, especially with disease-modifying antirheumatic drugs (DMARDs) and corticosteroids (infection risk, blood glucose, bone density).

Lower-Limb Amputation and Residual Limb Care

Amputation of a lower limb is most often caused by peripheral vascular disease (PVD) or diabetes complications. A below-knee amputation (transtibial) preserves the knee, improving prosthetic function and energy use during walking.

Residual limb (stump) care:

Inspect the skin daily for redness, breakdown, or signs of infection.
Wash with mild soap and water; dry thoroughly.
Wrap the residual limb with elastic bandages in a figure-eight pattern, starting at the distal end and working proximally. This shapes the limb for a prosthesis and reduces edema. Rewrap every 4–8 hours and whenever it loosens.
Position the residual limb to prevent flexion contractures—avoid prolonged elevation after the first 24–48 hours unless ordered.

Phantom limb pain is real neurologic pain perceived in the absent limb. Validate the patient's experience; do not dismiss it. Pharmacologic and non-pharmacologic interventions (mirror therapy, massage, medications as ordered) may help. Report uncontrolled pain to the RN.

Psychosocial support: Amputation causes grief over body image and function. Use therapeutic communication, involve the patient in care decisions, and collaborate with social work, physical therapy, occupational therapy, and prosthetist—all key members of the interdisciplinary team.

Safety Priorities

Always apply a transfer belt before any standing transfer.
Keep bed in the lowest locked position when not providing care.
Call for help before transferring a patient who exceeds safe handling weight limits.
Report changes in neurovascular status, wound appearance, or uncontrolled pain to the supervising RN immediately.
Document all mobility activities and patient responses accurately.

Key terms10

Hip precautionsPost-hip-replacement movement restrictions that prohibit hip flexion beyond 90 degrees, leg adduction past midline, and internal rotation of the operative leg, to prevent prosthetic dislocation.

Log-rollingA two-or-more person technique for turning a patient as a single rigid unit to maintain spinal alignment, used after spinal surgery or injury.

Non-weight-bearing (NWB) gaitA crutch-walking pattern in which the affected limb bears no weight; the patient advances both crutches simultaneously and swings the unaffected leg forward.

Neurovascular assessmentEvaluation of circulation and nerve function distal to a fracture or cast, using the five P's: Pain, Pallor, Pulse, Paresthesia, and Paralysis.

Phantom limb painPainful sensations perceived in a limb that has been amputated, caused by neurologic signals from the central and peripheral nervous system; it is a real and recognized clinical condition.

Residual limb (stump) wrappingApplication of elastic bandages in a figure-eight pattern from distal to proximal on an amputated limb to reduce edema and shape the limb for prosthetic fitting.

Transfer belt (gait belt)A sturdy belt secured around a patient's waist to give caregivers a safe handhold during standing transfers, reducing fall and injury risk.

Rheumatoid arthritis (RA)A chronic systemic autoimmune disease causing bilateral, symmetrical synovial joint inflammation, morning stiffness, and potential joint deformity.

Axillary crutch palsyCompression injury of the brachial plexus caused by incorrect crutch use in which the patient bears weight through the axilla instead of the hands.

ContracturePermanent shortening of muscle or connective tissue around a joint resulting from prolonged immobility or improper positioning, leading to limited range of motion.

In class: Instructor demonstration of safe patient handling techniques: log-rolling, repositioning in bed using a draw sheet, and two-person transfer to a chair for a post-hip-replacement patient (hip precautions); students practice each technique on a mannequin or consenting peer with instructor supervision. · Assistive device instruction and return demonstration: instructor demonstrates walker use, axillary crutch walking (non-weight-bearing gait), and cane use; each student performs one assigned technique in the hallway while the instructor observes for safety and correct weight distribution. · Case discussion on amputation and phantom limb pain: instructor presents a case of a patient with a below-knee amputation following peripheral vascular disease, covering residual limb care, stump wrapping technique demonstration, psychosocial support, and prosthetic preparation; students discuss interdisciplinary team roles.
Materials: Hospital bed with side rails, draw sheets, transfer belt, walker, axillary crutches, standard cane, stump wrapping elastic bandages, mannequin, Lewis's Medical-Surgical Nursing, safe patient handling policy reference
Check: Students safely demonstrate one assigned mobility or transfer technique with no safety errors (e.g., no unsupported patient, correct hip precautions maintained); pass = instructor sign-off on skills checklist; written scenario quiz scored at 80%.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.