Improving clinical examination in acute tibial fractures by enhancing visual cues: the case for always 'cutting back' a tibial back-slab and marking the dorsalis pedis pulse.

Look, feel, move is a simple and widely taught sequence to be followed when undertaking a clinical examination in orthopaedics (Maher et al., 1994; McRae, 1999; Solomon et al., 2010). The splinting of an acute tibial fracture with a posterior back-slab is also common practice; with the most commonly taught design involving covering the dorsum of the foot with bandaging (Charnley, 1950; Maher et al., 1994; McRae, 1989). We investigated the effect of the visual cues provided by exposing the dorsum of the foot and marking the dorsalis pedis pulse. We used a clinical simulation in which we compared the quality of the recorded clinical examination undertaken by 30 nurses. The nurses were randomly assigned to assess a patient with either a traditional back-slab or one in which the dorsal bandaging had been cut back and the dorsalis pedis pulse marked. We found that the quality of the recorded clinical examination was significantly better in the cut-back group. Previous studies have shown that the cut-back would not alter the effectiveness of the back-slab as a splint (Zagorski et al., 1993). We conclude that all tibial back-slabs should have the bandaging on the dorsum of the foot cut back and the location of the dorsalis pedis pulse marked. This simple adaptation will improve the subsequent clinical examinations undertaken and recorded without reducing the back-slab's effectiveness as a splint.

Improving the management of tibia stress fractures: a collaborative, outpatient clinic-based quality improvement project.

PURPOSE: Implement and evaluate the effectiveness of the Leg Pain Screening and Referral Tool (LPS&RT) for patients presenting with lower extremity leg pain in an outpatient clinic. SAMPLE: A total of 46 patients diagnosed with tibia stress fractures. METHODS: The study employed a pre-/postintervention design. Retrospective and prospective information was collected from an electronic health record to obtain patient data. The pre- and postintervention groups were compared on the number of patients diagnosed with tibia stress fractures. Provider adherence to the treatments recommended by the algorithm was assessed by chart audits postintervention. RESULTS: There was a significant increase (87.5%) in tibia stress fracture diagnosis, from 16 preintervention to 30 postintervention. Provider adherence to the LPS&RT was 93.3% postintervention. Common treatments were activity restriction, oral medication, and/or specialty referrals. CONCLUSION: The LPS&RT was an effective, uniform measure to standardize the plan of care for tibia stress fractures in one outpatient clinic.

Postoperative impact of daily life after primary treatment of proximal/distal tibiafracture with Ilizarov external fixation.

AIMS AND OBJECTIVES: To describe patients' experience of the impact of their health-related life situation on their daily life two and four weeks after primary fracture treatment with Ilizarov external fixation. BACKGROUND: A few studies have been conducted postoperatively focussing on fracture treatment with Ilizarov fixation. DESIGN: A prospective descriptive research design. METHOD: Patients who had been treated for a proximal/distal tibial fracture were invited to participate in the study. Data were collected with a semi-structured questionnaire where 20 patients described in their own words their situation at home two and four weeks postoperatively. The process used when analysing the data was similar to content analysis. RESULTS: Four key themes were identified: 'limitations in the home environment', 'limitations outside the home', 'limitations to social relations' and 'experience of having an Ilizarov fixation'. The patient's life situation was strongly affected during the first postoperative month. This took the form of clear limitations on activities outside the home and a degree of limitation on coping with household chores and personal hygiene. These limitations became less severe after between 2-4 weeks and were very much a consequence of using crutches. CONCLUSION: This study points to limitations in the patient's daily life situation in the home. The results from the study make it obvious that the information given to patients prior to discharge, concerning the value of putting weight on the leg, had not been clear or that the patients had not understood it. This had a negative impact on the patient's daily life after discharge. Further data are needed to uncover the extent of the issue to be able to optimise patient outcomes. RELEVANCE TO CLINICAL PRACTICE: There is a need for clearer and more active information from the nurse before discharge but also a need to follow up how the information given is understood.

Anterior tibial spine fracture - an easy fracture to miss.

Fractures of the intercondylar tibial spine are uncommon injuries that occur more frequently in the growing skeleton. They are easy to miss in the triage setting often being diagnosed as 'sprains' after sporting injuries. We report three cases that occurred in adolescents attending the same sporting event. We seek to highlight the importance of recognising these injuries so that the appropriate immediate treatment can be given.

Surgical treatment of patients with open tibial fractures.

Open tibial fractures are true surgical emergencies because of the risk of extensive infection to bone and devitalized soft tissue. The most serious consequence of open tibial fractures is osteomyelitis, which usually can be prevented by prompt surgical intervention within six to eight hours after injuries occur. Open tibial fractures often are the result of trauma from motor vehicle collisions, farm accidents, falls from heights, or gunshot wounds. Initial management of patients with multiple trauma injuries focuses on their life-threatening injuries before or during orthopedic surgical intervention for open tibial fractures. Orthopedic surgeons often work in collaboration with general, vascular, and plastic surgeons and perform multiple surgical procedures (eg, fasciotomy procedures for compartment syndromes, irrigation and debridement of wounds, application of external fixation devices, placement of intramedullary nails, possible limb amputations). The type and extent of open tibial fractures and soft tissue injuries determine the best treatment options for patients. Perioperative nurses should help patients focus on treatment choices for their open tibial fractures that ensure optimal surgical outcomes and maintain their quality of life.

On the receiving end.

Four years ago I was a tired and angry parent when I put pen to paper to record my experiences which are now printed in the ensuing article. Today I can look back without being so influenced by the protective instincts of parenthood and communicate objectively to all nurses who work in the paediatric field.