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
Introduction
The fundamentals of clinical practice are history, clinical examination and diagnosis synthesis (Maher et al, 1994, Talley, 2010). These remain difficult to quantify in a reliable fashion and many factors have been shown to play a role when misdiagnosis occurs (Berner, Graber, 2008, Graber et al, 2002, Graber et al, 2005, Reyna, Lloyd, 2006). Many clinical examinations also show relatively poor inter- and intra-observer correlation and yet the need to be able to begin with a relevant history and examination is the starting point for any diagnosis.
Visual cues have a recognised role in the clinical examination of patients in all specialities (Salk et al., 1998). In orthopaedics the simple principle of ‘Look, Feel, Move’ is taught widely, having initially been popularised by Alan Graham Apley circa 1940 (Maher et al, 1994, McRae, 1989, McRae, 1999, Solomon et al, 2010).
An adverse event in our hospital prompted the review of our neurovascular examination and documentation procedure and prompted this study. An incomplete examination had been undertaken of a patient who had undergone multiple surgeries including bilateral lower limb surgeries. The patient was intubated on the critical care unit and had had both lower limbs splinted in backslabs. It was subsequently noted that the patient had developed an ischaemic leg secondary to compartment syndrome. To be able to undertake the more complete examination that led to the diagnosis, the bandaging on the dorsum of the foot had to be ‘cut back’. This cutting back was followed by cutting back the rest of the dorsal bandaging over the leg to enable assessment of the affected compartments. It was noted that the initial cutting back facilitated the ability to ‘look’, which had then intuitively led on to a more complete ‘feel’ and ‘move’ examination. This more complete examination had captured the vital clinical signs that are required to evaluate an acutely injured leg, especially one that is developing neurovascular compromise and/or developing compartment syndrome. An experienced and competent nurse, familiar with treating patients with acutely injured limbs, undertook the initial incomplete examination. Did this nurse do something that others would routinely not? How much of a barrier does the bandaging on the dorsum of the foot present? Is this bandaging necessary to fulfil the function of a backslab? We set out to explore these questions.
Section snippets
Background and literature
A literature review was undertaken prior to undertaking the study so as to ascertain the available evidence and guidance in the areas of concern. This was then repeated prior to completion of this article. We undertook a standard PubMed search using the terms splint, back-slab, compartment syndrome and clinical examination (review articles were included). The lead author then assessed the abstracts for relevance and obtained the full texts of those articles most relevant to the study. The
Methods
Permission was sought and granted by the research department at our institution. We were satisfied by the study undertaken by Zagorski et al. (1993), on the stability of tibial fractures by external splints, that the cut-back would not alter the effectiveness of the back-slab.
A group of orthopedically educated nurses was assigned by random number allocation to record the clinical observations of one of the splinted limbs of a volunteer as illustrated in Fig. 1, Fig. 2. The nurses were recruited
Results
In all, 30 nurses were recruited into the study. Sixteen were allocated to the cut-back assessment and 14 to the traditional assessment (the difference was due to an administrative error in which, on the second day of the project, the sequence of allocations was started from the previous day's last allocation. This did not alter the validity of the statistical modelling or the process of randomisation). There was no significant difference in the average years experience or years in orthopaedic
Discussion
Our study showed that the simple act of cutting back the bandaging on the dorsum of a back-slab had a significant positive effect on subsequent clinicalobservations. Interestingly the area of day-to-day practice, seniority and length of service of the nurse performing the observations did not have an effect on clinical observations.
An assessment of an injured lower limb would not routinely be focused purely on eliciting the findings of a compartment syndrome, as other ‘neurovascular’
Conclusion
The application of all posterior back-slabs for acute tibia fractures should incorporate cutting back of the bandaging on the dorsum of the foot and marking of the dorsalis pedis pulse. This will improve the quality of subsequent clinical observations and reduce the chances of serious adverse events.
Conflict of Interest Statement
There is no conflict of interest of any of the authors with any financial organization regarding the material discussed in this manuscript.
Funding Source
This study was undertaken as part of Flinders Medical Centre's on-going clinical improvement projects and was funded via the Orthopaedic Department's independent Research and Audit budget.
Ethical Approval
This study, which was involving human subjects, is in accordance with the Helsinky declaration of 1975 as revised in 2000 and has been approved by the relevant institutional Ethical Committee.
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