ONC cheat sheet

The five Ps of neurovascular assessment are pain, pallor, pulselessness, paresthesia, and paralysis; temperature, capillary refill, and edema are assessed at the same time.

Capillary refill of 2 seconds or less is normal; a delay beyond 2 seconds suggests arterial insufficiency or hypovolemia.

An intracompartmental pressure above 30 mmHg, or within 30 mmHg of diastolic pressure, supports a diagnosis of compartment syndrome.

Deep tendon reflexes are graded 0 (absent) to 4+ (hyperactive with clonus); 2+ is normal.

Manual muscle testing: 0 = no contraction, 1 = trace, 2 = motion without gravity, 3 = against gravity, 4 = against some resistance, 5 = normal.

Dermatome landmarks: C6 thumb, C7 middle finger, T4 nipple line, T10 umbilicus, L4 medial malleolus, L5 dorsum of the foot, S1 lateral heel.

Lachman test assesses the anterior cruciate ligament, McMurray test assesses meniscal tears, and Phalen and Tinel tests assess carpal tunnel syndrome.

Reference range of motion: knee flexion 135 degrees, hip flexion 120 degrees, shoulder flexion 180 degrees, elbow flexion 150 degrees.

Neurovascular checks are typically every 1 to 2 hours immediately after injury, casting, or surgery, then every 4 hours once the patient is stable.

Fracture healing phases: hematoma and inflammation (days 0 to 5), soft callus (weeks 1 to 3), hard callus (weeks 3 to 6 and beyond), and remodeling (months to years).

Estimated blood loss from closed fractures: femur 1 to 1.5 L, pelvis up to 3 L, tibia 0.5 to 1 L.

Salter-Harris classification SALTR: I = slip through the physis, II = above (metaphysis), III = lower (epiphysis), IV = through both, V = crush (rammed).

Fat embolism syndrome classically presents with hypoxemia, neurologic changes, and a petechial rash 24 to 72 hours after a long-bone fracture.

Open fracture priorities: cover the wound, give intravenous antibiotics within 1 hour, update tetanus status, and proceed to irrigation and debridement.

Traction weights hang freely, are never removed or lifted by staff, and must not rest on the floor or bed frame.

Buck's skin traction typically uses 5 to 10 lb, whereas skeletal traction for a femoral shaft fracture commonly uses 15 to 30 lb per order.

Reduction may be closed (traction or manipulation) or open (internal fixation); immobilization follows with cast, splint, or external fixator.

Compartment syndrome risk is highest with tibial shaft fractures, supracondylar humeral fractures, and crush injuries.

Osteoarthritis is noninflammatory, with joint-space narrowing, osteophytes, and subchondral sclerosis; Heberden nodes occur at the distal and Bouchard nodes at the proximal interphalangeal joints.

Rheumatoid arthritis causes symmetric small-joint synovitis, morning stiffness lasting over 1 hour, positive rheumatoid factor or anti-CCP, ulnar deviation, and swan-neck deformity.

Dual-energy x-ray absorptiometry T-scores: normal is -1.0 or higher, osteopenia is -1.0 to -2.5, and osteoporosis is -2.5 or lower.

Adults generally require 1000 to 1200 mg of calcium and 800 to 1000 IU of vitamin D daily for bone health.

Gout shows needle-shaped, negatively birefringent monosodium urate crystals; the first metatarsophalangeal joint is most often affected, and alcohol and organ meats are triggers.

Pseudogout involves positively birefringent rhomboid calcium pyrophosphate crystals and most commonly affects the knee.

Paget disease of bone shows markedly elevated alkaline phosphatase with bone pain and deformity, and carries risk of pathologic fracture and osteosarcoma.

Ankylosing spondylitis is associated with HLA-B27, sacroiliitis, and a bamboo spine; stiffness improves with exercise rather than rest.

Septic arthritis presents with fever and a hot, swollen joint; synovial fluid white count above 50,000 with neutrophil predominance supports the diagnosis.

Cervical cord injuries at C3 to C5 threaten the phrenic nerve and diaphragm; a C5 injury leaves deltoid and biceps function with tetraplegia.

Neurogenic shock is hypotension with bradycardia and warm, dry skin from loss of sympathetic tone; treatment is fluids, vasopressors, and atropine for bradycardia.

Spinal shock is flaccid paralysis with absent reflexes and sensation below the lesion, resolving over days to weeks.

Autonomic dysreflexia occurs with lesions at T6 or above and causes severe hypertension, bradycardia, pounding headache, flushing, and diaphoresis; sit the patient upright and find the noxious stimulus, usually bladder distension.

Cauda equina syndrome presents with saddle anesthesia, bowel or bladder dysfunction, and bilateral leg pain or weakness and requires emergency MRI and decompression.

With cervical precautions, maintain spinal alignment using log-roll turns; a halo vest is not removed by nursing and requires pin-site care plus frequent neurologic checks.

Neurogenic claudication from lumbar spinal stenosis worsens with standing or walking and improves with flexion, such as leaning forward or sitting.

Scoliosis bracing is considered at a Cobb angle of 25 to 40 degrees in a growing child; spinal fusion is often considered above 40 to 50 degrees.

A straight leg raise that reproduces radicular pain between 30 and 70 degrees suggests L4 to S1 nerve root irritation.

Pediatric bone is more porous with a thicker periosteum and open growth plates, producing greenstick, torus (buckle), and Salter-Harris fracture patterns.

Developmental dysplasia of the hip is screened with the Ortolani maneuver (reduces a dislocated hip) and the Barlow maneuver (dislocates a reducible hip).

The Ponseti method treats clubfoot with serial manipulation and casting, often a percutaneous Achilles tenotomy, followed by a foot-abduction orthosis.

Legg-Calve-Perthes disease is idiopathic avascular necrosis of the femoral head in children aged 4 to 10 years, presenting with limp and groin or knee pain.

Slipped capital femoral epiphysis occurs in obese adolescents with groin or referred knee pain and an out-toeing gait; the patient is kept non-weight-bearing until pinning.

Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle in active adolescents, with pain on kneeling, jumping, and direct pressure.

Nursemaid's elbow is radial head subluxation in children under 5 after an axial pull; it is reduced by supination and flexion of the forearm.

Scoliosis screening uses the Adams forward bend test, with referral for truncal asymmetry or a measurable Cobb angle.

Osteogenesis imperfecta results from a type I collagen defect and presents with blue sclerae, recurrent fractures, and short stature.

A wet cast is handled with the palms rather than the fingertips, kept exposed to air, elevated, and iced for the first 24 to 48 hours.

Report burning, odor, drainage, or pain unrelieved by medication after casting, and never place objects inside a cast to scratch the skin.

Posterior-approach total hip arthroplasty precautions: no hip flexion beyond 90 degrees, no adduction past midline, and no internal rotation; an abduction pillow and raised toilet seat are used.

After total knee arthroplasty, continuous passive motion and early ambulation are used, and pharmacologic venous thromboembolism prophylaxis is commonly continued for up to 35 days.

Traction setup requires weights hanging free, ropes seated in pulley grooves, no weights on the floor, and no lifting of the patient free of traction without an order.

Tourniquet inflation time during limb surgery is generally limited to about 2 hours, and the team is notified before deflation.

Prophylactic antibiotics are administered within 60 minutes of incision and redosed for prolonged cases or large blood loss.

Preoperative verification includes informed consent, surgical site marking, NPO status, allergy review, and a team time-out before incision.

Pin site care includes daily cleansing and monitoring for erythema, drainage, or loosening that suggests pin tract infection.

Compartment syndrome signs: pain out of proportion, pain on passive stretch, a tense compartment, and paresthesia; pulselessness is a late and ominous finding.

For suspected compartment syndrome, remove constricting dressings, keep the limb at heart level rather than elevated, give analgesia, notify the surgeon, and anticipate fasciotomy.

Deep vein thrombosis presents with unilateral calf swelling, warmth, and pain; Homan sign is unreliable, and duplex ultrasound confirms the diagnosis.

Pulmonary embolism presents with sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia after surgery or immobility and requires emergency oxygen and anticoagulation.

Fat embolism syndrome presents with hypoxemia, confusion, and a petechial rash 24 to 72 hours after long-bone fracture; management is supportive oxygen and fracture stabilization.

Osteomyelitis is treated with 4 to 6 weeks of intravenous antibiotics and may require surgical debridement; fever, bone pain, and elevated ESR and CRP are typical.

Multimodal analgesia pairs scheduled acetaminophen or NSAIDs with opioids; a rapidly escalating PCA demand may signal a surgical complication.

Sedation precedes opioid-induced respiratory depression, so monitor respiratory rate and sedation scale; naloxone reverses opioid effects.

Fall prevention includes a low locked bed, call light within reach, nonskid footwear, hourly rounding, and Morse Fall Scale risk scoring.

Crutch fitting: the axillary pad sits 2 to 3 finger widths below the axilla, handgrips are at wrist height with arms at the sides, and elbows flex 15 to 30 degrees.

A cane is held in the hand opposite the affected leg; a walker is advanced first, followed by the weaker leg, then the stronger leg.

Gait patterns: three-point for non-weight-bearing, two-point for partial weight-bearing, four-point for maximal stability, and swing-through for paraplegic ambulation.

Weight-bearing orders include non-weight-bearing, touch-down, partial (up to 50 percent), weight-bearing as tolerated, and full; the order is never changed without the provider.

Isometric exercise contracts muscle without joint motion, isotonic exercise moves the joint through range under constant load, and isokinetic exercise maintains a constant speed.

Joint protection in rheumatoid arthritis includes respecting pain, using larger joints for leverage, avoiding prolonged gripping, and alternating activity with rest.

Discharge teaching after joint replacement covers anticoagulant adherence, mobility goals, wound care, and reporting calf pain, chest pain, or dyspnea.

Teach-back confirms comprehension by having the patient restate or demonstrate the instruction in their own words before discharge.

SBAR handoff stands for Situation, Background, Assessment, and Recommendation and structures transfer of care communication.