Foundational orthopaedic trauma knowledge for GCC clinical nursing practice — assessment frameworks, injury classification, and regional epidemiology.
GCC Burden: The Gulf region has among the highest road traffic accident (RTA) rates globally. Construction-related injuries are a major driver of orthopaedic trauma admissions, particularly among South and Southeast Asian expatriate workers.
Common Orthopaedic Trauma Types
Long Bone Fractures
Femur — highest energy; significant haemorrhage risk (1–2L blood loss into thigh)
Tibia — most common open fracture site; anterior compartment at risk
Humerus — radial nerve at risk with midshaft # (wrist drop)
Polytrauma common in high-mechanism GCC RTAs
Fat embolism risk with long bone fractures — monitor for confusion, hypoxia, petechiae
Pelvic Fractures
High-energy mechanism — RTAs, falls from height
Massive haemorrhage risk — pelvic ring disruption can accommodate several litres of blood
Pelvic binder pre-hospital or on arrival — do not remove without senior instruction
Perform neurovascular assessment distal to the fracture on admission, after any intervention (splinting, cast, surgery), and regularly throughout care. Document findings clearly with time.
5 Ps
Pain — out of proportion or on passive stretch
Pallor — capillary refill >2 seconds, pale digits
Pulselessness — absent or diminished distal pulse
Paraesthesia — tingling or numbness in nerve territory
Paralysis — inability to move distal segment
Neurovascular Assessment Technique
Compare bilaterally where possible
Capillary refill — press nail bed 5 seconds, should blanch and refill in <2 seconds
Regular multimodal analgesia — paracetamol, NSAIDs (if no contraindication), opioid as required
Regional anaesthesia may be in place — check infusion site
Reassess pain score post-intervention
Adequate pain control enables early physiotherapy
30-Day Mortality 5–10%: Hip fracture in the elderly carries significant mortality risk. Optimised pre-operative preparation, early surgery, and multidisciplinary care reduce this risk substantially.
Garden I/II: internal fixation (screws/DHS); Garden III/IV: hemiarthroplasty or THR
Extracapsular — Intertrochanteric
Between greater/lesser trochanters
Evans classification
Dynamic Hip Screw (DHS) or Intramedullary nail
Extracapsular — Subtrochanteric
Below lesser trochanter, proximal femur
Seinsheimer classification
Long intramedullary nail
BOAST/Blue Book Standards
Surgery within 36 hours of admission (ideally within 24 hrs for fit patients) — delay beyond 36 hrs associated with increased mortality, complications, and pressure injuries. Nurse advocates for timely theatre slot when medically optimised.
Pre-Operative Nursing
Analgesia & Nerve Block
Adequate analgesia is a nursing priority — pain untreated increases delirium risk
Femoral nerve block (FNB) or fascia iliaca block — effective for hip fracture pain; nurse monitors block site, motor block effect on limb
Regular paracetamol (unless contraindicated) as base
Avoid excessive opioids in frail/elderly — respiratory depression, constipation, delirium
Pain assessment using appropriate scale — Abbey scale if cognitive impairment
Fluid & Medical Optimisation
IV access on admission — commence IV fluids if dehydrated
Maintain urine output >0.5mL/kg/hr — IDC if needed
Correct anaemia pre-op — transfuse if Hb <80g/L (assess individually)
Review anticoagulants — withhold as per protocol; reversal if indicated
Electrolyte correction — K+, Na+
Chest physiotherapy — prophylactic in elderly
Pressure Area Prevention — HIGH RISK
Commence pressure area care from admission — immobility + poor nutrition + frailty = very high risk
Pressure-relieving mattress from admission
2-hourly repositioning (log roll with assistance)
Heel protection devices — heel fractures/ulcers common in this group
Document Waterlow/Braden score; escalate if high risk
Cognitive Assessment — Delirium Prevention
Cognitive baseline assessment on admission (AMT-4 or full AMTS)
Posterior Approach THR — Risk of Posterior Dislocation: Nurse must reinforce precautions at every interaction.
No hip flexion beyond 90° (no bending forward to knee level)
No internal rotation of operative leg (toes must not turn inward)
No adduction past midline (no crossing legs)
Practical Measures
Raised toilet seat — prevents flexion >90°
High chairs — armchairs preferable; avoid low chairs
Abduction pillow in bed between legs
Shoes and socks — occupational therapist to assess aids needed
Anterior approach — fewer restrictions; confirm with surgeon which precautions apply.
Day 1 Physiotherapy Mobilisation
Target: standing and walking frame on Day 1 post-op
Nurse to assist if physiotherapist not available — do not delay for routine obs alone
Weight-bearing status as directed — most hip fractures are full weight-bearing
Monitor for orthostatic hypotension on first stand — take BP lying and standing
Adequate analgesia 30–45 mins before physiotherapy session
Document distance walked, aid used, supervision level
Dislocation Warning Signs
Sudden severe hip pain + shortened/rotated leg = suspected dislocation. Keep patient in bed, call orthopaedic team immediately. Do NOT attempt reduction on ward.
Post-Discharge Falls Prevention
Discharge Planning Checklist
SURGICAL EMERGENCY: Acute compartment syndrome (ACS) requires immediate recognition and fasciotomy. Delay causes irreversible muscle necrosis, permanent nerve damage, and limb loss. Nurses are often first to identify early signs.
Pathophysiology & Causes
How ACS Develops
Compartments are enclosed by inelastic fascia — pressure cannot escape
Pain on passive stretch is the most reliable early sign. Gently extend the toes/fingers of the affected extremity — disproportionate pain = urgent escalation.
Pain out of proportion to injury or increasing pain despite adequate analgesia
Pain on passive stretch of muscles in the compartment — most reliable early sign
Tense, wooden compartment on palpation — compare with contralateral side
Increasing analgesic requirements — NCA or PCA escalation pattern
Late Signs — Compartment Already Ischaemic
Do NOT wait for pulselessness or paralysis before escalating. These represent established ischaemia and irreversible damage.
Paraesthesia — tingling, numbness in nerve territory of affected compartment
Weakness/paralysis — inability to dorsiflex foot (anterior compartment leg)
Pallor — pale digits
Pulselessness — absent dorsalis pedis or posterior tibial — very late, compartment already destroyed
Most Common Compartments
Location
Compartment
Passive Stretch Test
Nerve at Risk
Associated Fracture
Leg
Anterior (most common)
Passive plantarflexion (stretch toe extensors)
Deep peroneal nerve → foot drop
Tibial shaft fracture
Leg
Deep posterior
Passive toe extension
Tibial nerve
Tibial fracture, crush
Forearm
Volar (flexor)
Passive finger extension
Median nerve → carpal tunnel
Both bones forearm, supracondylar
Thigh
Anterior
Passive knee flexion
Femoral nerve
Femoral shaft fracture
Hand
Intrinsic/dorsal
Passive finger abduction
Deep ulnar
Metacarpal fractures, crush
Compartment Pressure Measurement
Fasciotomy threshold: Compartment pressure >30 mmHg OR Delta pressure (Diastolic BP − Compartment pressure) ≤ 30 mmHg — whichever criterion is met first. Clinical judgement always takes precedence.
Fasciotomy Post-Op Nursing
Immediate Post-Fasciotomy Care
Wounds left open — moist wound dressings (saline-soaked gauze or negative pressure dressing)
Neurovascular observations every 1 hour initially — document pain, pulses, sensation, movement
Elevation — but not excessive (reduces perfusion pressure) — limb at heart level
Myoglobinuria — dark/cola-coloured urine after rhabdomyolysis; aggressive IV fluids, monitor renal function
Return to theatre for delayed primary closure or split skin graft at 48–72 hrs
Escalation Pathway
If ACS suspected:
Remove all constrictive dressings, bivalve cast immediately
Do NOT elevate limb above heart level
Bleep/call orthopaedic registrar or consultant IMMEDIATELY
Prepare for urgent theatre — nil by mouth, consent
Document time of first concern and all actions
Escalate via chain of command if response delayed
Compartment Syndrome Risk Tracker
Compartment Syndrome Risk Assessment Tool
Symptom Checklist — tick all that apply:
Total Hip Replacement (THR) Post-Op Nursing
Immediate Post-Op (Recovery & Day 0)
ABCDE assessment on handover from theatre/recovery
Wound drain — measure and record hourly; drain typically removed at 24 hrs or <50mL/shift
Neurovascular observations: 15 min × 4, 30 min × 4, then hourly initially
Limb alignment — correct position, abduction pillow if posterior approach
Urinary catheter — remove by Day 1 if possible (infection and mobility risk)
IV → oral fluids when tolerating; antiemetics as needed
DVT Prophylaxis Protocol
LMWH — start 6–12 hrs post-op (confirm with surgeon and anaesthetist)
Aspirin (75–150mg) in some protocols — check local guidelines
TED stockings — correctly sized and fitted; remove for skin inspection BD
Intermittent pneumatic compression (IPC) devices — in use until ambulant
Encourage ankle pumps, dorsiflexion exercises from recovery
Early mobilisation Day 1 — single most effective DVT prevention
Anticoagulation duration: typically 28–35 days post-THR per NICE/local guidance
Leg Length Assessment
Clinical leg length may appear different post-op — explain to patient
Assess by examining relative positions of both feet with patient supine
True vs. apparent leg length — document for surgeon review
Significant discrepancy (>2cm) — inform surgical team
Shoe raise may be required at follow-up if persistent discrepancy
Dislocation — Warning Signs
Sudden severe hip pain + abnormal leg position = possible dislocation — EMERGENCY
Posterior dislocation: leg appears shortened, internally rotated
Anterior dislocation: leg extended and externally rotated
Keep patient supine — do NOT attempt repositioning on ward
Inform surgical team immediately for urgent management
Analgesia and reassurance while awaiting review
Check and reinforce hip precautions with patient post-reduction
Total Knee Replacement (TKR) Post-Op Nursing
Swelling, Cold Therapy & CPM
Cold therapy (cryocuff or ice pack in towel) — 20 min on/off; reduces swelling and pain
Continuous passive motion (CPM) machine — prescribed by surgeon; start at 0–30° then increase
Elevate leg on pillows — but with knee supported, NOT hanging in flexion
Compression bandage — monitor for tightness, neurovascular checks
Target flexion at discharge: typically 90° (able to sit comfortably)
Quadriceps Exercises & Mobility
Static quadriceps (quad sets) — start in recovery; improves extension
Straight leg raises — from Day 1 if able
Physiotherapy from Day 1 — walking frame initially, then sticks
Stair practice before discharge — ensuring competency on both up and down
Extension is critical — patient must achieve full extension (0°)
Scar massage taught at follow-up — prevents keloid in at-risk patients
Infection Prevention — Both THR & TKR
Wound Monitoring Protocol
Inspect wound every shift — any discharge, redness, warmth, swelling
Temperature trend — rising temperature post Day 2 is suspicious
CRP trend — expected to rise then fall after Day 3; rising or persistently elevated CRP = concern
WBC — leukocytosis post-op can be normal; trend matters
Any wound discharge = send swab, inform surgical team urgently
Wound dehiscence — cover with saline dressing; do NOT allow to dry out; urgent review
Blood Conservation Strategies
Pre-operative IV iron — corrects iron-deficiency anaemia pre-surgery; reduces transfusion need
Cell salvage (intraoperative) — re-infusion of shed blood from wound; nurse to manage cell salvage drain correctly
Tranexamic acid — reduces intraoperative blood loss; given IV or topical per protocol
Target Hb pre-op: >130g/L ideal; review if <100g/L post-op
Monitor drain output — >500mL/shift from single drain = inform surgeon
Joint Replacement Discharge Checklist
Construction Worker Fracture Patterns in GCC
Demographic: The GCC construction workforce is predominantly young male migrant workers from South and Southeast Asia. High-energy injuries from falls from scaffolding and ladders are common, often resulting in complex polytrauma.
Injury Patterns — Falls from Height
Calcaneal (heel) fractures — axial loading from height; bilateral in simultaneous bilateral landing
Massive haemorrhage protocol if indicated — damage control resuscitation
Pelvic binder application for suspected pelvic fracture
Spinal immobilisation until cleared clinically and radiologically
Thorough secondary survey — catalogue all fractures
Photography of open wounds before dressing — medicolegal documentation
Language Barriers & Communication
Patient Safety in Multilingual Environments
Hip precautions MUST be explained in the patient's language. A patient who does not understand precautions is at high risk of dislocation post-discharge. Use professional interpreters, pictograms, and translated written instructions.
Common Languages in GCC Orthopaedic Wards
Arabic (local and Egyptian/Levantine dialects)
Hindi / Urdu / Punjabi — Indian subcontinent workers
Bengali / Nepali / Sinhalese — South Asian workers
Tagalog / Bisaya — Filipino nursing and construction workforce
English — professional / expatriate patients
Communication Strategies
Hospital interpreter service — request in advance for post-op education
Pictogram instruction sheets — hip precautions, cast care, non-weight-bearing
Bilingual family member — supplement but do not replace professional interpreter for clinical information
Video resources in patient's language — increasingly available
Discharge letter translated if possible
Heat & Wound Care in GCC Summer
Environmental Challenges
Summer temperatures 40–50°C — increased perspiration under casts and bandages
Skin maceration under casts — accelerated by heat and humidity
More frequent cast checks and skin inspection required in summer months
Wound healing impaired by dehydration — encourage adequate fluid intake
Outdoor workers: wounds exposed to dust and contamination
Simulation training for ACS recognition increasingly available in GCC
Key References & Guidelines
BOAST Standards — British Orthopaedic Association Surgical Trauma guidelines
NICE CG124 — Hip Fracture Management
AO Surgery Reference — fracture classification and surgical principles
Gustilo & Anderson (1976) — open fracture classification
WHO Surgical Safety Checklist — applied pre-operatively
ATLS 10th Edition — American College of Surgeons
Garden (1961) — intracapsular hip fracture classification
DHA / MOH UAE Clinical Protocols — local adaptation of international standards
GCC Orthopaedic Trauma Nursing Guide — For clinical reference and educational purposes. Always follow local hospital protocols and seek senior guidance for individual patient management decisions. | ← All Guides