Complications, Pain Management, and Patient Safety
Compartment syndrome
The classic six Ps: pain out of proportion, pain with passive stretch, pressure (tense compartment), paresthesia, pallor, and pulselessness - but pulselessness and paralysis are late and unreliable. The earliest sensitive sign is pain with passive stretch of the compartment muscles. Remove constricting casts, dressings, and splints and notify the surgeon immediately; do not elevate the limb above heart level and do not rely on opioids to settle the pain.
Thromboembolism and fat embolism
Deep vein thrombosis and pulmonary embolism present with unilateral swelling, calf tenderness, dyspnea, or sudden deterioration; prophylaxis is mechanical plus pharmacologic per order. Fat embolism syndrome 24–72 hours after long-bone fracture presents with hypoxemia, neurologic change, and a petechial rash on the chest, axillae, and conjunctivae; support oxygenation and report.
Pain and safety
Use multimodal analgesia: scheduled acetaminophen and NSAIDs where appropriate, opioids at the lowest effective dose, and regional techniques. Assess with a validated tool matched to age and cognition. PCA safety: only the patient presses the button, no family-activated dosing, naloxone available, and monitor sedation and respiratory rate rather than the number alone. Opioid-naive older adults and patients with sleep apnea or renal impairment need closer monitoring. Fall risk, pressure injury, delirium, and wrong-site surgery are all preventable-harm categories.
Rule of thumb
Rising pain unrelieved by the ordered analgesic and worse on passive stretch is a compartment syndrome warning - escalate immediately rather than medicating again.