A nurse is teaching an elderly client with osteoporosis and a recent left hip replacement how to use crutches for partial weight-bearing. Which instruction should the nurse provide to ensure safe crutch walking?

The client is an elderly individual with osteoporosis who has just undergone a left hip replacement. The nurse must teach safe crutch ambulation while adhering to a partial weight-bearing (PWB) restriction. The primary safety concern is preventing a fall, which could lead to periprosthetic fracture or implant failure, especially given the underlying poor bone quality. The correct instruction focuses on establishing a stable base of support before initiating any movement.

Placing the crutch tips 6 inches in front and 6 inches to the side of each foot. This instruction describes the standard tripod position, which is the foundational starting and resting stance for crutch walking. The 6-inch anterior and lateral placement creates a wide, stable base of support that significantly reduces the risk of losing balance. This position ensures the client's center of gravity remains within the boundaries of the support base, preventing the crutches from slipping forward or the client from swaying sideways. For a client with osteoporosis and a recent hip replacement, a fall from an unstable stance could be catastrophic, making this foundational safety instruction the highest priority. Effective mobility interventions after hip fracture surgery, as evaluated in systematic reviews, emphasize structured gait training that begins with establishing postural stability and a safe starting position ^[1].

Option 2: Leaning forward on the crutches when walking to maintain balance. This is a dangerous instruction. Leaning forward shifts the body's center of gravity anteriorly, promoting a flexed posture and increasing the risk of the crutches slipping backward. It does not enhance balance; rather, it destabilizes the client. Proper crutch walking involves an upright posture with the elbows slightly flexed, looking straight ahead, not down at the feet.

Option 3: Placing all weight on the axilla when using the crutches. This is a critical safety error. Weight must be borne by the hands and arms via the hand grips, not the axillary (underarm) bars. Sustained pressure on the axillae can compress the radial nerve, leading to a condition known as crutch palsy, which manifests as wrist drop and sensory loss in the posterior arm and forearm. The nurse should be able to fit 2 to 3 finger-widths between the axilla and the crutch pad.

Option 4: Moving the injured leg and both crutches simultaneously in a three-point gait. This describes a three-point gait, which is indeed the correct gait pattern for non-weight bearing (NWB) on one leg. However, the question stem specifies that the client is partial weight-bearing. For PWB, the appropriate gait is typically a three-point gait where the injured leg and crutches advance together, but the foot is allowed to touch the floor with a prescribed amount of weight, or a modified two-point gait may be used. More importantly, this option describes a dynamic movement sequence without first establishing the safe starting position, which is the fundamental prerequisite for any gait training. The initial instruction must always be the stable tripod stance.