NUR 6210 EXAM 3 STUDY
GUIDE 2026/2026
Fractures
William Paterson University
NUR 6210
,Nur
NUR 6210 Exam 3
Fractures – a broken bone; can range from a thin crack to a complete break; bone can fracture crosswise, lengthwise, in several
places or into many pieces; most fractures happen when a bone is impacted by more force or pressure than it can support
1. a. Closed/simple= Bone breaks but there is no puncture to skin; b. open/compound = the ends of the broken bone
tear your skin; c. stable/nondisplaced = broken ends of the bone line up and are barely out of place; d.
unstable/displaced = broken ends of the bone do not line up;
2. a. Transverse fracture = has a horizontal fracture line; b. linear fracture = vertical fracture line; c. oblique fracture =
this type of fracture has an angled pattern; d. spiral fracture = fracture spirals around bone; e. greenstick = fracture
is incomplete and common in children whose bones are still soft; f. comminuted fracture = bone shatters into three
or more pieces
-most common causes of fractures: trauma, osteoporosis, overuse (stress fracture); PE and Imagining: take a good history of
injury; examine area of pain, swelling, ROM, deformity; x-ray is usually needed to confirm diagnosis of fracture
-clinical presentation: pain that prevents movement or weight bearing -point tenderness; swelling and tenderness around
injury, bruising, and deformity (a limb may look “out of place” or a part of the bone may puncture through the skin)
-treatment: immobilization can take place in Primary Care; further treatment may require referral to Ortho for cast
immobilization, functional cast or brace, external fixation, or open reduction and internal fixation; Recovery may take several
weeks or months
Carpal tunnel syndrome = repetitive stress injury; entrapment/compressive neuropathy of the median nerve of the wrist;
etiology: repetitive movement, pregnancy, obesity, arthritis, DM, HTN, hypothyroidism, trauma
-presentation: patients may present with intermittent wrist pain and numbness and tingling that radiates from palm of thumb,
index finger, middle finger and medial aspect of ring finger; patient may report intermittent nocturnal paresthesia, pain and
tightness at wrist and forearm that increases with activity, and an inability to hold objects or tendency to drop things
-a. flick’s sign = waking up from symptoms and shaking out hand to provide relief; b. hypalgesia – 2 point discrimination test =
diminished pinprick sensation in the distribution of median nerve (palmar aspect of index finger) compared to pinprick
sensation over ipsilateral little finger on affected hand; c. Square wrist sign = increased depth-to-width ratio; d. classic or
probable pattern = in classic pattern, symptoms affect at least two of digits 1, 2, or 3 – it includes symptoms in the fourth and
fifth digits, wrist pain and radiation of pain proximal to wrist but excludes symptoms on palm or dorsum of hand (SO PAIN
EVERYWHERE ARM, WRIST AND FINGERS BUT NOT PALM); in probable pattern, same symptom patterns as classic except
palmar symptoms are possible unless confined solely to ulnar aspect (PAIN CAN OCCUR IN FIRST THREE FINGERS including
the palm area OR THE FOURTH AND FIFTH FINGER including palm in that area = half the palm hurts depending on which
fingers are affected); e. thumb abduction weakness = ask patient to raise thumb perpendicular to palm then apply downward
pressure on distal phalanx (on thumb) while patient resists
-Phalen’s test = flex patient’s wrist 90 degrees with elbow in full extension – pain or paresthesia in fingers innervated by
median nerve within 60 seconds is a positive result (backs of hands pushed against each other); Tinel’s sign = repeatedly tap
the volar surface of patient’s wrist over the transverse carpal ligament – pain or paresthesia in fingers innervated by median
nerve is a positive result (tap the center of inner wrist)
-differential diagnoses: cervical radiculopathy, arthritis, neuropathy; diagnostics: history and PE, x-ray, Labs: CBC, ESR, ANA,
RF, TSH, electromyography and nerve conduction studies
-treatment: nonpharmacological = rest, work-home modification, ice, splinting, physical therapy – ultrasound; pharmacological
= NSAIDs, Steroids (oral or injection by hand specialist); Surgical = carpal tunnel release
-another non-surgical treatment if no improvement in 2-7 weeks; conservative management for 6 weeks to 3 months; refer to
orthopedist or hand specialist if symptoms severe or no improvement
Gout – systemic metabolic disease; term used to refer to a group of disease states caused by tissue deposition of monosodium
urate (MSU) as a result of prolonged hyperuricemia; hyperuricemia develops from excess uric acid production, a decrease in
the renal excretion or both – primary vs secondary hyperuricemia; 4 stages: asymptomatic hyperuricemia, acute gouty flares,
intercritical gout, and chronic tophaseous gout
-epidemiology: most common inflammatory arthritis in adults; prevalence increases with age; incidence of gout increasing in
most developed countries; male: female ratio is around 4:1; predominant age = 30-50 in men, older than 60 in women
-risk factors: 73% of all gout patients have mild to severe renal insufficiency; certain medications: diuretics, low-dose aspirin,
tacrolimus, cyclosporine; comorbidities: obesity, renal disease, HTN, metabolic syndrome; high levels of meat and seafood
consumption, overeating, alcohol consumption in men; lower body temperature, trauma, surgery, dehydration, starvation
-acute gout clinical presentation – rapid onset and buildup of pain, maximum pain within 4-12 hours; first flare often begins at
night and can wake the person from sleep; intense pain associated with warmth, redness, tenderness, swelling and decreased
ROM of the affected joint; initial episode usually monoarticular in men; in 50% of patient the first metatarsophalangeal joint
(toe) is the first one involved (known as podagral); other joints: insteps, heels, knees, wrists, fingers, elbows; systemic signs of
fatigue, fever and chills; untreated lasts several hours to several weeks
-chronic tophaseous gout clinical presentation = usually develops after 5-10 years of acute intermittent gout; characterized by
collection of solid urate along the chronic inflammatory and destructive changes in the connective tissue; tophus means “chalk
stone” in Latin; tophi appears as firm swellings, typically not painful or tender, may reveal a yellow or white color; most
common sites: digits of hands and feet, olecranon bursa, helix and antihelix of ear
,Nur
-diagnosis: even though clinical presentation strongly suggests gout, need to diagnose with needle aspiration (the presence of
MSU crystals in joint fluid or tophus is gold standard for diagnosis); joint aspiration is invasive and not always possible in
primary care setting; supportive data include history; elevated inflammatory markers (creatinine and SU level; x-ray is useful;
Ultrasound and icing (named the double contour sign) highly specific for diagnosis without needle aspiration of joint
, Nur
-recommendations: weight loss for obese patients to achieve BMI that promotes health, healthy diet, exercise, smoking
cessation, stay well hydrated; AVOID: organ meats, high in purine content (sweetbreads, liver, kidney), high fructose corn
syrup-sweetened sodas/beverages/foods, alcohol overuse (more than 2 servings a day for males and 1 serving per day for
female) in all gout patients (avoid any alcohol use in gout during periods of attacks or if under poor control); LIMIT: serving
sizes of beef, lamb, pork, seafood with high purine (sardines, shellfish), servings of naturally sweet fruit juices, table sugar,
sweetened beverages and dessert, table salt (sauces and gravies), limit (beer/wine/spirits); ENCOURAGE: low fat or non-fat
dairy products, vegetables
-pharmacologic management of acute gout: 1. first line therapy = NSAIDS – all NSAIDS are equally effective; any oral NSAID
may be given at the maximal dosage and continued for one to two days after relief of symptoms (ex: Indomethacin 50mg TID);
2.
Colchicine (thought to inhibit microtubule polymerization preventing neutrophil migration) is another treatment option for
acute gout – it is more effective during the first 12-24 hours of an attack, avoid using in patients with renal and hepatic
insufficiency*; Colchicine
1.2mg initially, then 0.6mg one hour later, then 0.6 to 1.2mg per day; 3. Corticosteroids are preferred therapy for patients in
whom NSAIDS and colchicine are contraindicated; taper to avoid rebound flares; oral, IM or intra-articular routes, variable
dosing (prednisone 40mg for four days, then 20mg for four days, then 10mg for four days)
-chronic gout prevention – serum urate-lowering therapy (ULT) should be initiated to prevent recurrences in persons with
the following: history of gout, at least two flares per year (one per year in persons with chronic kidney disease stage 2 or
greater), tophi, a history of nephrolithiasis, ULT should be started 6-8 weeks after the flare has resolved and start at low doses
and increase slowly every 4-6 weeks to reach serum urate level of less than 6mg/dl
-serum urate monitoring: normal serum urate levels do not exclude the diagnosis of gout; SU should be monitored every 2 -5
weeks while titrating dose, then very 6 months; ULT should be continued for three to six months after a flare if there are no
ongoing symptoms; therapy should continue indefinitely if there are ongoing signs or symptoms or having one or more tophi
on examination
-treatment for chronic gout: Xanthine oxidase inhibitors (Uricostatic drugs that decrease uric acid synthesis) – Allopurinol
(Zyloprim) 100mg per day initially except in patients with renal dysfunction, common effective dosage is 300mg per day but
higher dosages may be needed; Febuxostat (Uloric) 40mg once per day, may increase up to 80mg per day if serum uric acid
level > 6mg per dL (357 mmol per L) after two weeks
-geriatric considerations: avoid loop and thiazide diuretics if they have HTN and gout because these agents can increase uric
acid levels; calcium channel blockers and the ARB Losartan are associated with a decreased risk of incident gout; Losartan is
the only angiotensin receptor blocker with this property; Indomethacin is avoided in older adults because of the greater risk
of adverse effects compared with other NSAIDs; Glucocorticoids are generally tolerated in short-term use for acute attacks in
patients in whom NSAIDs or colchicine may pose an increased risk; contraindications to the use of NSAIDs in older adults =
presence of heart failure, renal impairment or GI disease such as ulcers; contraindication to colchicine include GI intolerance,
dosing restrictions in patients with renal and hepatic dysfunction and potential drug interactions and also may include the
high cost of therapy
-referral= rheumatologist consultation indications = establish the diagnosis by joint aspiration and MSU crystal identification,
drug toxicity or intolerance occurs, if patient still develops acute flares with the maximum tolerated treatment, if the diagnosis
is in doubt, patient is unable to use or tolerate medication
-follow up: acute gout = 1 week; Chronic gout = 2 months; patient education: identification of characteristics crystals,
education regarding medications: acute gout to prevent further gout/chronic gout, patients with chronic gout will require
lifetime treatment to lower uric acid body pool, and lifestyle changes = controlling weight, limiting alcohol, limiting meals with
meats and fish rich in purines, increasing low-fat dairy consumption and consuming cherries to control gout
Lower back pain –usually mechanical in nature or degeneration, systemic medical illness cause is rare (neoplasm, infection);
radiculopathy is caused by inflammation, impingement or injury of nerve root – pain to buttocks posterior thigh and down to
the knee/s; L4-L-5 and L5-S1 are most commonly affected; men = women
-classification: a. acute: less than 6 weeks in duration; b. subacute: 6 weeks to 3 months in duration; c. chronic: >3 months or
more than half days in prior 3 months
-assessment: identify movement and position causing pain or relief, associated symptoms; Red flags = a. cauda equina
(compression of multiple lumbosacral nerve roots) – bladder dysfunction, perineal sensory loss, neurologic deficit and
weakness of lower extremities; b. vertebral fracture: prolonged use of corticosteroids, older than 70 years old, history of
osteoporosis and recent significant infection related to lower back pain: fever over 100.4, history of IV drug use, severe pain,
lumbar spine surgery within the last year or immunocompromised states (use of systemic steroids, organ transplant, DM,
HIV), pain that is worse when laying down;
c. cancer related lower back pain – history of cancer, recent diagnosis of cancer, weight loss >10kg within 6 months with no
explanation, being 50 years or under 18 years of age, failure to improve with therapy, pain lasting for more than 4 to 6 weeks
and pain at night or pain at rest
-PE: a. M/S Spine = curvature, inflammation, tenderness (spams); ROM – note limitation, anterior involvement – pain with
forward flexion, posterior involvement (most common) – pain with extension; length of extremity discrepancy; gait and
ambulation; b. Neuro
= Strength: hip flexion, hip abduction, knee extension and flexion, ankle flexion, foot eversion, great toe extension, calf raises;
GUIDE 2026/2026
Fractures
William Paterson University
NUR 6210
,Nur
NUR 6210 Exam 3
Fractures – a broken bone; can range from a thin crack to a complete break; bone can fracture crosswise, lengthwise, in several
places or into many pieces; most fractures happen when a bone is impacted by more force or pressure than it can support
1. a. Closed/simple= Bone breaks but there is no puncture to skin; b. open/compound = the ends of the broken bone
tear your skin; c. stable/nondisplaced = broken ends of the bone line up and are barely out of place; d.
unstable/displaced = broken ends of the bone do not line up;
2. a. Transverse fracture = has a horizontal fracture line; b. linear fracture = vertical fracture line; c. oblique fracture =
this type of fracture has an angled pattern; d. spiral fracture = fracture spirals around bone; e. greenstick = fracture
is incomplete and common in children whose bones are still soft; f. comminuted fracture = bone shatters into three
or more pieces
-most common causes of fractures: trauma, osteoporosis, overuse (stress fracture); PE and Imagining: take a good history of
injury; examine area of pain, swelling, ROM, deformity; x-ray is usually needed to confirm diagnosis of fracture
-clinical presentation: pain that prevents movement or weight bearing -point tenderness; swelling and tenderness around
injury, bruising, and deformity (a limb may look “out of place” or a part of the bone may puncture through the skin)
-treatment: immobilization can take place in Primary Care; further treatment may require referral to Ortho for cast
immobilization, functional cast or brace, external fixation, or open reduction and internal fixation; Recovery may take several
weeks or months
Carpal tunnel syndrome = repetitive stress injury; entrapment/compressive neuropathy of the median nerve of the wrist;
etiology: repetitive movement, pregnancy, obesity, arthritis, DM, HTN, hypothyroidism, trauma
-presentation: patients may present with intermittent wrist pain and numbness and tingling that radiates from palm of thumb,
index finger, middle finger and medial aspect of ring finger; patient may report intermittent nocturnal paresthesia, pain and
tightness at wrist and forearm that increases with activity, and an inability to hold objects or tendency to drop things
-a. flick’s sign = waking up from symptoms and shaking out hand to provide relief; b. hypalgesia – 2 point discrimination test =
diminished pinprick sensation in the distribution of median nerve (palmar aspect of index finger) compared to pinprick
sensation over ipsilateral little finger on affected hand; c. Square wrist sign = increased depth-to-width ratio; d. classic or
probable pattern = in classic pattern, symptoms affect at least two of digits 1, 2, or 3 – it includes symptoms in the fourth and
fifth digits, wrist pain and radiation of pain proximal to wrist but excludes symptoms on palm or dorsum of hand (SO PAIN
EVERYWHERE ARM, WRIST AND FINGERS BUT NOT PALM); in probable pattern, same symptom patterns as classic except
palmar symptoms are possible unless confined solely to ulnar aspect (PAIN CAN OCCUR IN FIRST THREE FINGERS including
the palm area OR THE FOURTH AND FIFTH FINGER including palm in that area = half the palm hurts depending on which
fingers are affected); e. thumb abduction weakness = ask patient to raise thumb perpendicular to palm then apply downward
pressure on distal phalanx (on thumb) while patient resists
-Phalen’s test = flex patient’s wrist 90 degrees with elbow in full extension – pain or paresthesia in fingers innervated by
median nerve within 60 seconds is a positive result (backs of hands pushed against each other); Tinel’s sign = repeatedly tap
the volar surface of patient’s wrist over the transverse carpal ligament – pain or paresthesia in fingers innervated by median
nerve is a positive result (tap the center of inner wrist)
-differential diagnoses: cervical radiculopathy, arthritis, neuropathy; diagnostics: history and PE, x-ray, Labs: CBC, ESR, ANA,
RF, TSH, electromyography and nerve conduction studies
-treatment: nonpharmacological = rest, work-home modification, ice, splinting, physical therapy – ultrasound; pharmacological
= NSAIDs, Steroids (oral or injection by hand specialist); Surgical = carpal tunnel release
-another non-surgical treatment if no improvement in 2-7 weeks; conservative management for 6 weeks to 3 months; refer to
orthopedist or hand specialist if symptoms severe or no improvement
Gout – systemic metabolic disease; term used to refer to a group of disease states caused by tissue deposition of monosodium
urate (MSU) as a result of prolonged hyperuricemia; hyperuricemia develops from excess uric acid production, a decrease in
the renal excretion or both – primary vs secondary hyperuricemia; 4 stages: asymptomatic hyperuricemia, acute gouty flares,
intercritical gout, and chronic tophaseous gout
-epidemiology: most common inflammatory arthritis in adults; prevalence increases with age; incidence of gout increasing in
most developed countries; male: female ratio is around 4:1; predominant age = 30-50 in men, older than 60 in women
-risk factors: 73% of all gout patients have mild to severe renal insufficiency; certain medications: diuretics, low-dose aspirin,
tacrolimus, cyclosporine; comorbidities: obesity, renal disease, HTN, metabolic syndrome; high levels of meat and seafood
consumption, overeating, alcohol consumption in men; lower body temperature, trauma, surgery, dehydration, starvation
-acute gout clinical presentation – rapid onset and buildup of pain, maximum pain within 4-12 hours; first flare often begins at
night and can wake the person from sleep; intense pain associated with warmth, redness, tenderness, swelling and decreased
ROM of the affected joint; initial episode usually monoarticular in men; in 50% of patient the first metatarsophalangeal joint
(toe) is the first one involved (known as podagral); other joints: insteps, heels, knees, wrists, fingers, elbows; systemic signs of
fatigue, fever and chills; untreated lasts several hours to several weeks
-chronic tophaseous gout clinical presentation = usually develops after 5-10 years of acute intermittent gout; characterized by
collection of solid urate along the chronic inflammatory and destructive changes in the connective tissue; tophus means “chalk
stone” in Latin; tophi appears as firm swellings, typically not painful or tender, may reveal a yellow or white color; most
common sites: digits of hands and feet, olecranon bursa, helix and antihelix of ear
,Nur
-diagnosis: even though clinical presentation strongly suggests gout, need to diagnose with needle aspiration (the presence of
MSU crystals in joint fluid or tophus is gold standard for diagnosis); joint aspiration is invasive and not always possible in
primary care setting; supportive data include history; elevated inflammatory markers (creatinine and SU level; x-ray is useful;
Ultrasound and icing (named the double contour sign) highly specific for diagnosis without needle aspiration of joint
, Nur
-recommendations: weight loss for obese patients to achieve BMI that promotes health, healthy diet, exercise, smoking
cessation, stay well hydrated; AVOID: organ meats, high in purine content (sweetbreads, liver, kidney), high fructose corn
syrup-sweetened sodas/beverages/foods, alcohol overuse (more than 2 servings a day for males and 1 serving per day for
female) in all gout patients (avoid any alcohol use in gout during periods of attacks or if under poor control); LIMIT: serving
sizes of beef, lamb, pork, seafood with high purine (sardines, shellfish), servings of naturally sweet fruit juices, table sugar,
sweetened beverages and dessert, table salt (sauces and gravies), limit (beer/wine/spirits); ENCOURAGE: low fat or non-fat
dairy products, vegetables
-pharmacologic management of acute gout: 1. first line therapy = NSAIDS – all NSAIDS are equally effective; any oral NSAID
may be given at the maximal dosage and continued for one to two days after relief of symptoms (ex: Indomethacin 50mg TID);
2.
Colchicine (thought to inhibit microtubule polymerization preventing neutrophil migration) is another treatment option for
acute gout – it is more effective during the first 12-24 hours of an attack, avoid using in patients with renal and hepatic
insufficiency*; Colchicine
1.2mg initially, then 0.6mg one hour later, then 0.6 to 1.2mg per day; 3. Corticosteroids are preferred therapy for patients in
whom NSAIDS and colchicine are contraindicated; taper to avoid rebound flares; oral, IM or intra-articular routes, variable
dosing (prednisone 40mg for four days, then 20mg for four days, then 10mg for four days)
-chronic gout prevention – serum urate-lowering therapy (ULT) should be initiated to prevent recurrences in persons with
the following: history of gout, at least two flares per year (one per year in persons with chronic kidney disease stage 2 or
greater), tophi, a history of nephrolithiasis, ULT should be started 6-8 weeks after the flare has resolved and start at low doses
and increase slowly every 4-6 weeks to reach serum urate level of less than 6mg/dl
-serum urate monitoring: normal serum urate levels do not exclude the diagnosis of gout; SU should be monitored every 2 -5
weeks while titrating dose, then very 6 months; ULT should be continued for three to six months after a flare if there are no
ongoing symptoms; therapy should continue indefinitely if there are ongoing signs or symptoms or having one or more tophi
on examination
-treatment for chronic gout: Xanthine oxidase inhibitors (Uricostatic drugs that decrease uric acid synthesis) – Allopurinol
(Zyloprim) 100mg per day initially except in patients with renal dysfunction, common effective dosage is 300mg per day but
higher dosages may be needed; Febuxostat (Uloric) 40mg once per day, may increase up to 80mg per day if serum uric acid
level > 6mg per dL (357 mmol per L) after two weeks
-geriatric considerations: avoid loop and thiazide diuretics if they have HTN and gout because these agents can increase uric
acid levels; calcium channel blockers and the ARB Losartan are associated with a decreased risk of incident gout; Losartan is
the only angiotensin receptor blocker with this property; Indomethacin is avoided in older adults because of the greater risk
of adverse effects compared with other NSAIDs; Glucocorticoids are generally tolerated in short-term use for acute attacks in
patients in whom NSAIDs or colchicine may pose an increased risk; contraindications to the use of NSAIDs in older adults =
presence of heart failure, renal impairment or GI disease such as ulcers; contraindication to colchicine include GI intolerance,
dosing restrictions in patients with renal and hepatic dysfunction and potential drug interactions and also may include the
high cost of therapy
-referral= rheumatologist consultation indications = establish the diagnosis by joint aspiration and MSU crystal identification,
drug toxicity or intolerance occurs, if patient still develops acute flares with the maximum tolerated treatment, if the diagnosis
is in doubt, patient is unable to use or tolerate medication
-follow up: acute gout = 1 week; Chronic gout = 2 months; patient education: identification of characteristics crystals,
education regarding medications: acute gout to prevent further gout/chronic gout, patients with chronic gout will require
lifetime treatment to lower uric acid body pool, and lifestyle changes = controlling weight, limiting alcohol, limiting meals with
meats and fish rich in purines, increasing low-fat dairy consumption and consuming cherries to control gout
Lower back pain –usually mechanical in nature or degeneration, systemic medical illness cause is rare (neoplasm, infection);
radiculopathy is caused by inflammation, impingement or injury of nerve root – pain to buttocks posterior thigh and down to
the knee/s; L4-L-5 and L5-S1 are most commonly affected; men = women
-classification: a. acute: less than 6 weeks in duration; b. subacute: 6 weeks to 3 months in duration; c. chronic: >3 months or
more than half days in prior 3 months
-assessment: identify movement and position causing pain or relief, associated symptoms; Red flags = a. cauda equina
(compression of multiple lumbosacral nerve roots) – bladder dysfunction, perineal sensory loss, neurologic deficit and
weakness of lower extremities; b. vertebral fracture: prolonged use of corticosteroids, older than 70 years old, history of
osteoporosis and recent significant infection related to lower back pain: fever over 100.4, history of IV drug use, severe pain,
lumbar spine surgery within the last year or immunocompromised states (use of systemic steroids, organ transplant, DM,
HIV), pain that is worse when laying down;
c. cancer related lower back pain – history of cancer, recent diagnosis of cancer, weight loss >10kg within 6 months with no
explanation, being 50 years or under 18 years of age, failure to improve with therapy, pain lasting for more than 4 to 6 weeks
and pain at night or pain at rest
-PE: a. M/S Spine = curvature, inflammation, tenderness (spams); ROM – note limitation, anterior involvement – pain with
forward flexion, posterior involvement (most common) – pain with extension; length of extremity discrepancy; gait and
ambulation; b. Neuro
= Strength: hip flexion, hip abduction, knee extension and flexion, ankle flexion, foot eversion, great toe extension, calf raises;
