14.3 Progressive Ambulation, Assistive Device Prescriptions, Crutch Gaits, DVT Prophylaxis & Discharge Planning

Progressive Ambulation, Assistive Devices, VTE Prophylaxis & Discharge Planning

Core Clinical Principle: Safe functional rehabilitation following orthopaedic trauma or reconstructive surgery requires strict adherence to surgeon-prescribed weight-bearing restrictions, biomechanically precise assistive device fitting, structured gait training, vigilant venous thromboembolism (VTE) prophylaxis, and comprehensive home discharge planning. Competent orthopaedic nursing guidance directly prevents construct failure, falls, and debilitating complications.

1. Standardized Weight-Bearing Prescriptions

Prescribed weight-bearing limitations are engineered to protect surgical fixation, osteotomies, tendon repairs, and biological bone ingrowth into prosthetic components during critical healing phases.

                  WEIGHT-BEARING TERMINOLOGY & FORCE THRESHOLDS
  ┌─────────────────────────────────────────────────────────────────────────────┐
  │ Non-Weight-Bearing (NWB): 0% Body Weight                                    │
  │ • Operative extremity must NEVER touch the floor or support any body weight.│
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ Touch-Down / Toe-Touch Weight-Bearing (TDWB / TTWB): 10% – 15% Weight        │
  │ • Foot or toes touch the floor SOLELY for balance and posture.              │
  │ • Clinical Analogy: "Stepping on an egg without cracking the shell" or      │
  │   "resting on a potato chip without crushing it." NO heel-strike or push-off│
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ Partial Weight-Bearing (PWB): 20% – 50% Body Weight                         │
  │ • Prescribed percentage of body weight. Calibrated using a bathroom scale.  │
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ Weight-Bearing as Tolerated (WBAT): Variable (Comfort-Driven up to 100%)    │
  │ • Patient bears as much weight as tolerated by comfort and pain thresholds. │
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ Full Weight-Bearing (FWB): 100% Body Weight                                 │
  │ • Full unassisted weight-bearing; device used only for balance or endurance.│
  └─────────────────────────────────────────────────────────────────────────────┘

2. Assistive Device Fitting, Biomechanics & Sequences

Improperly fitted assistive devices alter center-of-gravity dynamics, dramatically increase metabolic energy expenditure, and predispose patients to falls and compressive peripheral neuropathies.

                     ASSISTIVE DEVICE SELECTION & FITTING STANDARDS
  ┌─────────────────────────────────────────────────────────────────────────────┐
  │ Standard / Rolling Walkers:                                                 │
  │ • Height: Handgrips level with GREATER TROCHANTER or ULNAR WRIST CREASE     │
  │ • Arm Posture: Elbows flexed 20° to 30° when standing erect inside walker.   │
  │ • Safety Rule: Push up from chair armrests to stand; NEVER pull on walker!  │
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ Straight Single-Point & Quad Canes:                                         │
  │ • Height: Handgrip level with GREATER TROCHANTER or ULNAR WRIST CREASE      │
  │ • Placement: Held in hand CONTRALATERAL (OPPOSITE) to the affected leg.     │
  │ • Quad Cane Base: Flat vertical side faces patient; flared legs face away.  │
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ Axillary Crutches:                                                          │
  │ • Axillary Clearance: 2 to 3 fingerbreadths (1.5–2 inches / 4–5 cm) below   │
  │   anterior axillary fold in tripod stance (tips 6" forward, 2" lateral).    │
  │ • Handgrips: Level with wrist crease, providing 20°–30° elbow flexion.      │
  │ • Critical Directive: Bear weight ON PALMS / HANDS; NEVER on axillary pads! │
  └─────────────────────────────────────────────────────────────────────────────┘

The Biomechanics of Contralateral Cane Placement

• The Rule: The cane is always held in the hand opposite (contralateral) to the operative or affected lower extremity.
• The Mechanism: When advancing the affected leg, holding the cane on the opposite side establishes a wide tripod base of support and shifts the center of mass away from the affected hip joint. This dramatically reduces the abductor muscle force required by the gluteus medius, decreasing joint reaction forces across the affected hip by over 50%.
• Gait Sequence: Advance the cane and the affected (operative) leg forward simultaneously, followed by the unaffected (strong) leg stepping past the cane.

Axillary Crutch Mechanics & Crutch Palsy Prevention

• The Danger: Allowing body weight to rest upon the top axillary pads compresses the brachial plexus (posterior cord) and the radial nerve within the axilla and spiral groove, resulting in crutch palsy (manifesting as radial neuropraxia, wrist drop, and paresthesia over the dorsal first web space).
• The Nursing Directive: Instruct patients that all body weight must be transmitted through the palms with extended, locked wrists. The axillary pads are squeezed gently against the lateral chest wall solely for lateral stabilization.

3. Specialized Crutch Gait Patterns & Stair Navigation

The selection of crutch gait is dictated by the patient's prescribed weight-bearing status, bilateral motor strength, balance, and coordination.

                      CRUTCH GAIT PATTERN CLASSIFICATION
  ┌─────────────────────┬──────────────────────────┬────────────────────────────┐
  │ Gait Pattern        │ Indication & WB Status   │ Step-by-Step Gait Sequence │
  ├─────────────────────┼──────────────────────────┼────────────────────────────┤
  │ 4-Point Gait        │ • Bilateral PWB or FWB   │ 1. Right crutch forward    │
  │ (Slowest, Most      │ • Requires coordination  │ 2. Left foot forward       │
  │  Stable)            │ • 3 points of ground     │ 3. Left crutch forward     │
  │                     │   contact always present │ 4. Right foot forward      │
  ├─────────────────────┼──────────────────────────┼────────────────────────────┤
  │ 2-Point Gait        │ • Bilateral PWB or FWB   │ 1. Right crutch and Left   │
  │ (Faster, Mimics     │ • Natural reciprocal arm │    foot advance together   │
  │  Normal Walking)    │   and leg movement       │ 2. Left crutch and Right   │
  │                     │                          │    foot advance together   │
  ├─────────────────────┼──────────────────────────┼────────────────────────────┤
  │ 3-Point Gait        │ • Unilateral NWB or PWB  │ 1. Advance BOTH crutches   │
  │ (Standard for       │   with ONE leg FWB       │    and affected leg forward│
  │  Fractures/Cast)    │ • Most common pattern    │ 2. Advance unaffected leg  │
  │                     │   in unilateral trauma   │    forward (swing-to/thru) │
  ├─────────────────────┼──────────────────────────┼────────────────────────────┤
  │ Swing-To &          │ • Bilateral lower limb   │ • Swing-To: Both crutches  │
  │ Swing-Through       │   paralysis / paraplegia │   advance, legs swing TO.  │
  │ Gaits               │ • Trunk / upper body     │ • Swing-Through: Crutches  │
  │                     │   strength dependent     │   advance, legs swing PAST │
  └─────────────────────┴──────────────────────────┴────────────────────────────┘

Stair Climbing Navigation Protocols

Stair navigation presents the highest fall risk during rehabilitation. Orthopaedic nurses must reinforce the universal clinical mnemonic:

4. Venous Thromboembolism (VTE) Prophylaxis & Surveillance

Major orthopaedic procedures (Total Hip Arthroplasty [THA], Total Knee Arthroplasty [TKA], and Hip Fracture Surgery) carry the highest baseline risk for Deep Vein Thrombosis (DVT) and fatal Pulmonary Embolism (PE) across surgical specialties due to the convergence of Virchow's Triad (venous stasis from immobility/tourniquet, endothelial vessel wall injury from surgical reaming/retraction, and systemic hypercoagulability).

                      EVIDENCE-BASED VTE PROPHYLAXIS PROTOCOLS
  ┌─────────────────────────────────────────────────────────────────────────────┐
  │ 1. Mechanical Prophylaxis (Mandatory for ALL patients):                     │
  │    • Intermittent Pneumatic Compression (IPC) / Sequential Compression (SCD)│
  │    • Must be worn continuously (minimum 18–20 hours/day) in bed and chair.  │
  │    • Augments venous return and stimulates endogenous tissue plasminogen    │
  │      activator (tPA) release from endothelial beds.                         │
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ 2. Pharmacologic Agents & Dosing Regimens:                                  │
  │    • Low-Molecular-Weight Heparin (LMWH): Enoxaparin 30 mg SC BID or        │
  │      40 mg SC daily (adjust dose for renal clearance <30 mL/min).           │
  │    • Direct Oral Anticoagulants (DOACs): Factor Xa inhibitors:              │
  │      - Apixaban (Eliquis) 2.5 mg PO BID                                     │
  │      - Rivaroxaban (Xarelto) 10 mg PO daily                                 │
  │    • Aspirin (ASA): 81 mg PO BID (AAOS/ACCP guideline-supported in         │
  │      standard-risk arthroplasty patients following initial in-hospital dose)│
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ 3. Duration of Pharmacologic Prophylaxis:                                   │
  │    • Total Knee Arthroplasty (TKA): Minimum 10 to 14 days (up to 35 days).  │
  │    • Total Hip Arthroplasty (THA) & Hip Fractures: EXTENDED PROPHYLAXIS for  │
  │      a minimum of 28 to 35 days postoperatively.                            │
  └─────────────────────────────────────────────────────────────────────────────┘

Clinical Surveillance for DVT and PE

• DVT Signs: Unilateral calf swelling (circumferential asymmetry $>2\text{--}3\text{ cm}$ measured at fixed tibial tuberosity distance), localized tenderness along the deep venous tract, erythema, and palpable cord. Note: Homans sign (calf pain on forced ankle dorsiflexion) is unreliable, non-specific, and potentially dangerous; duplex venous ultrasonography is the confirmatory gold standard.
• PE Signs: Sudden onset of dyspnea, tachypnea ($>20\text{ breaths/min}$), pleuritic chest pain, tachycardia ($>100\text{ bpm}$), unexplained hypoxemia, apprehension, and hemoptysis. Immediate nursing actions: apply high-flow oxygen, elevate head of bed, notify provider, and obtain emergent CT Pulmonary Angiography (CTPA).

5. Multidisciplinary Discharge Readiness & Home Safety Competencies

Prior to discharge, the orthopaedic nurse coordinates an interdisciplinary evaluation (physical therapy, occupational therapy, case management) to confirm functional independence and verify home environmental safety.

                  DISCHARGE READINESS COMPETENCY CHECKLIST
  ┌─────────────────────────────────────────────────────────────────────────────┐
  │ 1. Functional Transfer Mastery:                                             │
  │    [ ] Independent, safe bed-to-chair and chair-to-stand transfers.          │
  │    [ ] Safe toilet and shower transfers utilizing assistive grab bars.      │
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ 2. Ambulation & Stair Navigation:                                           │
  │    [ ] Independent ambulation of 100–150 feet on level household surfaces.   │
  │    [ ] Safe, independent navigation of the required number of stairs to     │
  │        enter and function within the home environment.                      │
  │    [ ] Correct adherence to prescribed weight-bearing restrictions.         │
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ 3. Clinical & Physiological Stability:                                      │
  │    [ ] Adequate pain control on oral multimodal analgesic regimens.         │
  │    [ ] Stable hemodynamics and clear baseline neurovascular status.         │
  │    [ ] Surgical wound clean, dry, and intact without active drainage.       │
  │    [ ] Active bowel sounds and successful elimination (bowel regimen active)│
  ├─────────────────────────────────────────────────────────────────────────────┤
  │ 4. Patient / Caregiver Education Competencies:                              │
  │    [ ] Verbalizes medication schedule, anticoagulation duration, and safety.│
  │    [ ] Demonstrates understanding of surgical precautions (e.g., THA).      │
  │    [ ] Recognizes red flag symptoms (DVT/PE, surgical site infection).      │
  └─────────────────────────────────────────────────────────────────────────────┘

Home Safety & Environmental Modifications

• Fall Hazard Elimination: Remove all throw rugs, scatter mats, and loose runner carpets; secure all electrical and telephone cords along baseboards; eliminate clutter along primary walking pathways.
• Bathroom Modifications: Install securely anchored grab bars (bolted into wall studs; never use suction-cup bars or towel racks) inside showers and adjacent to toilets; install an elevated/raised toilet seat (essential for posterior THA patients to prevent hip flexion $>90^\circ$); place non-skid rubber mats inside and outside tubs/showers; utilize a sturdy shower chair or tub transfer bench.
• Seating & Furniture: Prescribe high, firm chairs with sturdy armrests to provide leverage during sitting and standing; strictly avoid low, soft, overstuffed recliners or rocking chairs.
• Lighting & Stairways: Ensure continuous, sturdy dual handrails along all interior and exterior staircases; install bright illumination and automatic nightlights in hallways, bedrooms, and bathrooms.
• Assistive Reachers: Provide long-handled reachers/grabbers, sock aids, and long-handled shoehorns so patients avoid acute spinal or hip flexion beyond prescribed limits.