ONP-C cheat sheet

Neurovascular assessment (5 Ps): pain, pallor, pulselessness, paresthesia, paralysis; paresthesia is often the earliest sign of compartment syndrome.

Ottawa Ankle Rules: X-ray indicated only if pain in malleolar zone plus bone tenderness at posterior edge of lateral or medial malleolus, or inability to bear weight 4 steps.

Ottawa Knee Rules: X-ray if age ≥55, isolated patellar tenderness, fibular head tenderness, inability to flex to 90°, or inability to bear weight 4 steps.

Cauda equina red flags: saddle anesthesia, new bowel/bladder dysfunction, bilateral sciatica, progressive motor deficit - emergent MRI.

On plain radiographs, occult scaphoid fracture is suspected with snuffbox tenderness; repeat views or MRI/CT if initial films are negative.

MRI is preferred for soft tissue, ligament, meniscus, and occult fracture; CT is preferred for complex articular fractures and preoperative planning.

Bone scan and MRI are more sensitive than plain films for early osteomyelitis; plain films may lag 10-14 days.

Dual-energy X-ray absorptiometry T-score ≤ -2.5 defines osteoporosis; -1.0 to -2.5 is osteopenia.

Osteoarthritis: joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts; managed with activity, weight loss, NSAIDs, injections, arthroplasty.

Rheumatoid arthritis: symmetric small-joint polyarthritis, morning stiffness >1 hour, anti-CCP and RF positive; early DMARD therapy limits erosion.

Rotator cuff tendinopathy: painful arc 60-120°, positive Neer and Hawkins tests; drop-arm sign suggests full-thickness tear.

Carpal tunnel syndrome: median nerve distribution numbness, positive Phalen and Tinel tests, thenar atrophy late; night splints and steroid injection first-line.

Plantar fasciitis: medial heel pain worse with first steps; managed with stretching, orthoses, night splint; steroid injection reserved.

Osteoporosis is silent until fracture; vertebral compression fractures present with acute back pain and height loss.

Fibromyalgia: widespread pain ≥3 months, no inflammatory markers, tender points historical; diagnosis is clinical.

Avascular necrosis risk factors: corticosteroids, alcohol, sickle cell disease, trauma; early MRI is most sensitive.

Fracture description: location, pattern (transverse, oblique, spiral, comminuted), displacement, angulation, rotation, shortening, articular involvement, open vs closed.

Gustilo-Anderson open fracture grading: I <1 cm clean; II 1-10 cm; IIIA adequate soft tissue coverage; IIIB requires flap; IIIC arterial injury requiring repair.

Open fracture initial management: tetanus status, IV antibiotics within 1 hour, saline irrigation, provisional splint, urgent debridement.

Compartment syndrome: pain out of proportion, pain with passive stretch, tense compartment; pressure >30 mmHg or within 30 mmHg of diastolic suggests fasciotomy.

Fat embolism syndrome: hypoxemia, petechiae, confusion after long bone fracture, typically 24-72 hours; supportive care.

Hip fracture in older adults: early surgery (within 24-48 hours when feasible) reduces complications; assess for anticoagulants and delirium.

Distal radius Colles fracture: dorsal displacement and angulation; Smith fracture is volar displacement.

Pediatric physeal injuries use Salter-Harris classification I-V; type I may have normal radiographs.

Multimodal analgesia combines acetaminophen, NSAIDs, opioids, and regional blocks to reduce opioid dose and adverse effects.

NSAIDs: caution with renal impairment, GI ulcer history, heart failure, and anticoagulation; COX-2 inhibitors carry cardiovascular risk.

Acetaminophen maximum 3-4 g/day in healthy adults; lower limits with hepatic disease or alcohol use.

Opioid initiation: lowest effective dose, bowel regimen, assess sedation and respiratory depression; naloxone reverses overdose.

Tramadol lowers seizure threshold and serotonergic risk; avoid with MAOIs and use caution with SSRIs.

Anticoagulation after arthroplasty: aspirin, LMWH, or direct oral anticoagulants per protocol; monitor for bleeding and wound hematoma.

Corticosteroid injections provide short-term relief; limit frequency due to cartilage and tendon weakening.

Antibiotic prophylaxis for orthopaedic surgery typically cefazolin; adjust for MRSA colonization or beta-lactam allergy.

Total hip arthroplasty approaches: posterior, direct anterior, lateral; each has distinct dislocation and nerve injury risk profiles.

Total knee arthroplasty: tourniquet use, cement fixation, gap balancing; monitor for periprosthetic joint infection and thromboembolism.

Periprosthetic joint infection workup: ESR, CRP, synovial fluid cell count and culture; chronic cases may need two-stage revision.

Arthroscopy: document compartment findings, cartilage grade, meniscal tear pattern; use fluid pump pressure cautiously to limit extravasation.

External fixation is used for damage control in polytrauma, open fractures, and unstable pelvis; pin site care prevents infection.

Intramedullary nailing is standard for femoral and tibial shaft fractures; monitor for fat embolism and compartment syndrome.

Surgical site infection prevention: preoperative antibiotics within 60 minutes, chlorhexidine skin prep, normothermia, glucose control.

Prophylaxis against venous thromboembolism follows risk stratification; early mobilization is a core component.

Postoperative neurovascular checks: circulation, sensation, motor function, and pain every 1-2 hours initially, then per protocol.

Early mobilization reduces delirium, thromboembolism, and length of stay after hip and knee arthroplasty.

Weight-bearing status: non-weight-bearing, touch-down, partial, weight-bearing as tolerated, full; follow surgeon orders.

Continuous passive motion is not routine for all knees; evidence is limited, and active range of motion is emphasized.

Strengthening after rotator cuff repair progresses from passive to active-assisted to active to resisted over weeks.

Fall prevention: assess gait, vision, medications, home hazards; use assistive devices and physical therapy.

Wound care: keep clean and dry per protocol; signs of infection include increasing pain, redness, drainage, fever.

Return-to-sport criteria are functional, not time-based: pain-free motion, strength symmetry, and sport-specific testing.

Teach back confirms understanding; ask patients to explain instructions in their own words.

Osteoporosis prevention: weight-bearing exercise, adequate calcium and vitamin D, smoking cessation, fall prevention.

Smoking cessation improves bone healing and reduces surgical complications; offer counseling and pharmacotherapy.

Opioid education: secure storage, disposal, constipation prevention, and not driving while sedated.

DVT warning signs: unilateral calf pain, swelling, warmth, redness; instruct patients to seek urgent care.

Weight management reduces knee osteoarthritis pain and load; each kilogram of weight loss reduces knee load about 4 kg per step.

Diabetes control improves wound healing; coordinate glucose management before elective surgery.

Teach home exercise adherence with written instructions, scheduled follow-up, and realistic goals.

Scope of practice is defined by state nurse practice acts and institutional policy; know delegation rules for assistive personnel.

Informed consent requires capacity, disclosure of risks and alternatives, and voluntary decision; the surgeon obtains consent.

HIPAA permits disclosure for treatment, payment, and operations; minimum necessary standard applies.

Advance directives and healthcare proxies guide care when the patient lacks capacity.

Documentation must be timely, objective, and complete; late entries are labeled as such.

Mandatory reporting includes suspected abuse and certain communicable diseases per state law.

Just culture distinguishes human error from reckless behavior; encourage event reporting without blame.

Reimbursement models include DRG-based inpatient payment and value-based programs; readmissions carry financial penalties.

Pediatric bones are more elastic; greenstick and buckle fractures are common, and remodeling potential is greater in younger children.

Salter-Harris type I and II generally have good prognosis; type III, IV, and V risk growth disturbance.

Developmental dysplasia of the hip screening: Ortolani and Barlow in infants; Pavlik harness for young infants.

Legg-Calvé-Perthes and slipped capital femoral epiphysis cause pediatric hip pain; SCFE needs surgical stabilization.

Older adults: polypharmacy, delirium, osteoporosis, and frailty increase surgical risk; comprehensive geriatric assessment improves outcomes.

Delirium prevention: orientation, sleep hygiene, early mobility, hydration, pain control, and minimizing anticholinergics.

Pressure injury prevention: repositioning, skin assessment, support surfaces, nutrition.

Falls are the leading cause of injury in older adults; multifactorial assessment reduces recurrence.

Primary survey: airway, breathing, circulation, disability, exposure; control hemorrhage before secondary assessment.

Pelvic fracture with hemodynamic instability: bind pelvis, activate massive transfusion protocol, consider angioembolization or external fixation.

Open fracture: antibiotics within 1 hour, tetanus prophylaxis, irrigation, splint, and urgent surgical debridement.

Septic arthritis: joint aspiration before antibiotics when feasible; empiric IV antibiotics and drainage.

Compartment syndrome is a clinical diagnosis; do not delay fasciotomy for imaging.

Fat embolism and pulmonary embolism present with hypoxia and tachycardia; maintain suspicion after long bone fracture or arthroplasty.

Necrotizing fasciitis: pain out of proportion, rapid spread, systemic toxicity; emergent surgical debridement.

Acute spinal cord injury: immobilize, maintain mean arterial pressure, and avoid hypotension; imaging before clearance.

Neurovascular assessment (5 Ps): pain, pallor, pulselessness, paresthesia, paralysis; paresthesia is often the earliest sign of compartment syndrome.

Ottawa Ankle Rules: X-ray indicated only if pain in malleolar zone plus bone tenderness at posterior edge of lateral or medial malleolus, or inability to bear weight 4 steps.

Ottawa Knee Rules: X-ray if age ≥55, isolated patellar tenderness, fibular head tenderness, inability to flex to 90°, or inability to bear weight 4 steps.

Cauda equina red flags: saddle anesthesia, new bowel/bladder dysfunction, bilateral sciatica, progressive motor deficit - emergent MRI.

On plain radiographs, occult scaphoid fracture is suspected with snuffbox tenderness; repeat views or MRI/CT if initial films are negative.

MRI is preferred for soft tissue, ligament, meniscus, and occult fracture; CT is preferred for complex articular fractures and preoperative planning.

Bone scan and MRI are more sensitive than plain films for early osteomyelitis; plain films may lag 10-14 days.

Dual-energy X-ray absorptiometry T-score ≤ -2.5 defines osteoporosis; -1.0 to -2.5 is osteopenia.