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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
International Journal of Orthopaedic and Trauma Nursing (2016) 22, 36–43
International Journal of Orthopaedic and Trauma Nursing www.elsevier.com/locate/ijotn
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 Alasdair Thomas FRCSEd (Tr & Orth), Dip MSK Med, MRCS, MB ChB (Fellow in Orthopaedic Trauma) a,*, Cheryl Kimber NP (Orthopaedic Nurse Practitioner) a, Donald Bramwell BSc (hons) (Head of Education) b, Ruurd Jaarsma MD, PhD, FRACS (Professor of Orthopaedics, Trauma Surgery) c a
Orthopaedic Department, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia International Musculoskeletal Research Institute, Department of Orthopaedic Surgery, Flinders Medical Centre, Bedford Park, SA 5042, Australia c Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia b
KEYWORDS Clinical examination; Tibial fracture; Visual cues; Backslab; Splint; Dorsalis pedis pulse; Compartment syndrome
Abstract 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 backslab 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).
* Corresponding author. Orthopaedic Department, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia. Tel.: +61 449 510 661; fax: +61 8 8374 0832. E-mail address: [email protected] (A. Thomas). http://dx.doi.org/10.1016/j.ijotn.2015.11.002 1878-1241/© 2015 Elsevier Ltd. All rights reserved.
Improving clinical examination in acute tibial fractures
37
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. © 2015 Elsevier Ltd. All rights reserved.
Editor comments Being able to visualise the skin and palpate pulses is central to the effective assessment and observation of a limb following trauma and/or orthopaedic surgery. Such activity can, however, be significantly restricted by the presence of a splint, a cast or bandages. This study identifies the value of making this practice much easier through the adaptation of the cast and bandages to facilitate assessment. It also demonstrates the importance of balancing the integrity of splints and casts with the need to be able to clearly identify the neurovascular status of the limb. JS-T
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 and Graber, 2008; Graber et al., 2002, 2005; Reyna and Lloyd, 2006). Many clinical examinations also show relatively poor inter- and intraobserver 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, 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.
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 standard orthopaedic textbooks used by junior doctors and nurses were also reviewed. This review showed that there were no articles that explored the potential benefit to the completeness of the clinical examination by exposing the dorsum of the foot of an acutely injured lower limb encased in a splint. Moreover, the general assumption that appeared to be made was that the limb would be suitably exposed to allow a full assessment in all circumstances. As this is not the case in
38 a high proportion of cases that we all come across in day-to-day practice, we felt there was a case to undertake the study and determine whether the dayto-day reality has an effect in undertaking optimum assessment and subsequent care. Back-slab is a term commonly given to a type of splint. It consists of encircling cotton/synthetic padding around an injured limb and then placing a slab of Plaster of Paris or equivalent material onto the padding and holding it in place with bandaging. The term back-slab is a universal term used to describe any type of slab and often is not related to its position on the limb. For this study a back-slab means a posterior slab. Applying a posterior slab to a leg is a relatively simple and quick procedure and is an important step used in the emergency or first aid treatment of fractures and significant soft tissue injuries. Back-slabs are also applied postoperatively after surgical fixation of a fracture or a soft tissue procedure. The design of a ‘traditional’ back-slab for a tibial fracture is based upon the principles that underlie the application of full casts; where the cast extends from the metatarsal phalangeal crease of the great toe to above the knee (Charnley, 1950; Maher et al., 1994; McRae, 1989, 1999). The ankle is routinely placed in a neutral position (the foot 90 degrees to the leg). This is a functional position, so rehabilitation is less hindered should stiffness be an issue on removal of the back-slab. This neutral position is also the optimum position to accommodate increases in compartment pressure (Weiner et al., 1994). Compartment syndrome is a well recognised and potentially devastating complication of an acute tibial fracture (Rorabeck and Macnab, 1976). The diagnosis is primarily a clinical one with intracompartmental pressure measurement providing further evidence of the diagnosis (Harris et al., 2006; Matsen et al., 1980; Mubarak et al., 1978). The clinical diagnostic element makes it a particularly difficult diagnosis to make in unconscious patients when a complete clinically evaluation is not feasible. In the setting of an acute tibial fracture the risk of compartment syndrome is well-recognised and incomplete documentation and evaluation has been previously reported (Cascio et al., 2005). Parameters to be considered should include the tenseness of the compartment in question, pulses, motor examination, sensory examination, pain on passive stretch, paraesthesia and pallor. Importantly, an overall assessment should be clearly documented (Cascio et al., 2005, 2008). Recent literature has proposed clinical practice guidelines and reviewed the literature on compartment syndrome and the importance of a complete
A. Thomas et al. clinical examination continues to be considered vital in the diagnosis (Ali et al., 2014; Wall et al., 2010).
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 Figs. 1 and 2. The nurses were recruited through volunteering during their routine shift in the hospital over a period of 2 days. The simulation took 10 minutes and all nurses approached agreed to take part. The ‘patient’ volunteer was a final year medical student who had been given clear instructions and had practiced displaying the signs and symptoms of compartment syndrome. His briefing included that his injury had been a fractured tibia sustained in a car crash earlier that day for which he had undergone intra-medullary nailing four hours previously. His pain was getting worse and was now worse than when he had sustained the injury and he was pressing his PCA as much as he could, the pain was 9/10 and down to 6/10 just after pressing his PCA, he was aware that movement of his toes increased the pain and that he had altered sensation in the first web space of the dorsum of his foot. The nurses were given the instructions described below. The nurses were blinded to the nature of the
Fig. 1
Traditional backslab.
Improving clinical examination in acute tibial fractures
39
Years on acute surgical ward: Years in Orthopaedic nursing: Clinical Entry:
Fig. 2
Cutback design.
study. They were also blinded to the differences in the designs of the back-slabs. The nurses were given the following written brief prior to taking part in the simulation: Thank you for participating in this exercise. It is important that you perform the task as described in the Scenario to the same standard as you would in real life. The observations should be noted as you would enter them into the medical notes, please also fill in the personal information section. As we shall repeat this exercise around the hospital, please do not discuss this project in detail with your colleagues at this time. You are not being assessed personally; we shall be giving group feedback at a later date. Thanks Again. The nurses were given the following scenario verbally and in written format and given the opportunity to clarify the simulation: The patient you are to examine is a post op patient. He underwent nailing of a fractured tibia 4 hours ago. The surgeon has asked for ‘close NV obs’ on the operated leg. The patient has been complaining of increasing pain over the past hour, but this has been controlled with their use of their PCA. Please perform standard clinical observations upon the operated leg, as you feel appropriate in this clinical setting. Underneath the written scenario were the headings listed below. The nurses completed these immediately after finishing their examination on the simulated patient. Position: Years Qualified:
To be able to evaluate the observations undertaken and recorded we constructed a scoring system prior to commencing the study. We used the peerreviewed standard of Cascio et al. in 2005 and 2008. The entries were given one point for each of the parameters reported as being important to be recorded in the situation of a possible compartment syndrome. These were: tenseness of the compartment in question, pulses, motor examination, sensory examination, pain on passive stretch, paraesthesia and pallor and an overall assessment. This gave a scoring system of 0–8 with which the clinical entries were then scored. The scorer was blinded to the type of backslab on which the clinical entry had been made. We considered that the experience and seniority of the nurse examining the patient may be a potential bias and therefore collected and analysed those data as well.
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 nursing between the two groups. There was a significant difference in the quality of the clinical observations recorded in favour of the cut-back group versus the traditional group (Mann– Whitney U Test; Sum of Ranks 311 vs. 154 (p < .005)). There was no significant correlation in the quality of clinical observations in relation to years of experience or years in orthopaedic nursing. Very few nurses recorded whether there was pain on passive stretch, the tenseness of the leg or parathesia, which are all considered cardinal signs of compartment syndrome. Only one nurse, when faced with the traditional assessment, palpated and recorded the presence of a pulse (Table 1).
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 clinical
40
Table 1 Backslab type
Table of results. Position Years Years on acute Years in Tenseness Pulses Motor Sensory Pain on Parathesia Pallor Overall Total qualified surgical ward orthopaedic of leg examination examination passive assessment score nursing stretch 4 1 2 1 10 1 7 0.5 4 1 30 0.2 3 25 1 9 4 1.5 0.3 20 4 23 0.01 1.5 3 5 10 2 3 19
1 0.5 2 0.1 10 0.5 7 0.4 2 1 20 0.2 3 15 0.5 0.2 2 1 0.1 10 1 1 0.01 0.3 3 4 10 0.2 1.5 19
0 0 0 0.1 0.1 0 7 0.4 0 0.5 20 0.2 3 15 0.1 0 0 0 0.1 2 0 1 0.01 0.3 3 4 10 0.2 1.5 19
0 0 0 0 1 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0
0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 1 1 1 0 1 1 1 1
0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
EN = Enrolled Nurse, RN = Registered Nurse, CN = Clinical Nurse, CNC = Clinical Nurse Consultant, GN = Graduate Nurse.
0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1
0 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 3 4 4 4 4 4 4 4 4 4 5 5 6 4 4 4 4 5 5 5 5 5 5 5 5 5 6 6 7
A. Thomas et al.
Traditional EN RN RN RN RN RN EN EN RN RN EN GN RN EN Cut back RN EN CN EN GN EN RN EN GN RN RN RN CNC RN RN CN
Improving clinical examination in acute tibial fractures observations. 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’ consequences of injury need to be elicited during a routine examination, i.e. isolated vascular injury, nerve injury and/or venous insufficiency. Given the scenario that prompted our study and the fact that an appropriate examination directed at eliciting compartment syndrome would elicit the other possible clinical entities, we were satisfied that our simulation should prompt a full assessment. Our study showed that, when faced with a clinical scenario designed to simulate a patient developing a clear case of compartment syndrome, very few nurses noted the key clinical findings that would allow the diagnosis to be made. Only 3 noted pain on passive stretch and only 3 noted parathesia. A thorough clinical history and examination are the bedrock of practising safe and effective clinical medicine. In this era of widespread evidence-based medicine, these vitally important skills that we base our day-to-day practice on are difficult to research as they are part of a multifactorial process. Diagnostic error is consistently reported at a 10–15% level. Schiff et al. (2009) reported that physicians recognise that a failure in clinical examination accounted for the diagnostic error in 10% of cases in their study. The role of visual cues is routinely taught throughout clinical medicine. There is an expectation that patients will be appropriately assessed visually as part of any routine clinical examination. The exact role of visual cues within the diagnostic process has not been studied independently, but the role of visual cues (aka visual triggers) in teaching medical students is recognised as a valuable prompt within a problem based learning environment (Azer, 2007). The power of visual prompts and cues within the field of visual perception and orientating has been studied and appropriate cueing items have a powerful effect (Guzzon et al., 2010). The marking of patients is used to identify the correct site for operations and it is now universally recommended that this occurs. In our study, we used a cross to mark an easily palpable dorsalis pedis pulse which led to the pulse being palpated and documented as present 69% of the time in a free-form clinical entry. We could not find any studies that had investigated the power of marking the pulse in relation to its future examination. It could be argued that the pulse should always be palpated when assessing a lower limb in the clinical simulation that we investigated. This was observed to take place
41
in our simulation in the cut-back design but it was only documented 69% of the time. The traditional tibial back-slab includes bandaging that creates a barrier to the pulse being palpated. The clinical reality is more likely as in our study where only one nurse felt underneath the bandaging and documented the pulse as present. The palpation of the dorsalis pedis pulse is considered a difficult art to perfect and potentially unreliable (Lundin et al., 1999). However the absence of a dorsalis pedis pulse is clinically significant and should lead to further evaluation. In our institution this would routinely be undertaken with a portable handheld Doppler instrument. With only the toes on display with a traditional design back-slab, capillary refill was routinely recorded in our study as an assessment of ‘pallor’, but this is known to be unreliable and was observed to be performed with an inconsistent method in our study as has been noted in other studies (Anderson et al., 2008). The weaknesses of our study are that we used a clinical simulation and did not observe patient examinations within routine clinical practice. We had to construct our own scoring system based on a published standard as no published validated scoring system exists. We could also have added a third arm were the dorsalis pedis pulse had not been marked. This may have further clarified whether marking the pulse had an independent effect on the scoring system used, rather than just the cutaway design. If we had increased the power in our study we may have detected other statistically significant differences in separate components of the score such as passive stretch or parathesia. On the basis of our study and review of the literature it is our opinion that traditional methods of splinting injured limbs and the teaching and performing of clinical evaluations continue to require critical scrutiny. We would recommend that whenever a splint is used in the treatment of an injured limb, the person applying it should consider: 1. How the splints are providing adequate stability. 2. How they may facilitate and highlight the need for continued clinical vigilance in the monitoring of the limb. As a consequence of our study we have developed a limb observation pro-forma that is used by the nursing staff in our hospital to evaluate and record the status of injured limbs. This highlights the signs and symptoms of compartment syndrome (Appendix S1). We encourage communication between clinical staff that highlights the signs and symptoms of compartment syndrome, at risk patients and the key clinical findings and we now
42 routinely expose the dorsum of the foot and mark the dorsalis pedis pulse.
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.
Appendix: Supplementary material Supplementary data to this article can be found online at doi:10.1016/j.ijotn.2015.11.002.
References Ali, P., Santy-Tomlinson, J., Watson, R., 2014. Assessment and diagnosis of acute limb compartment syndrome: a literature review. International Journal of Orthopaedic and Trauma Nursing 18 (4), 180–190. Anderson, B., Kelly, A.M., Kerr, D., Clooney, M., Jolley, D., 2008. Impact of patient and environmental factors on capillary refill time in adults. The American Journal of Emergency Medicine 26 (1), 62–65. Azer, S.A., 2007. Twelve tips for creating trigger images for problem-based learning cases. Medical Teacher 29 (2–3), 93– 97. Berner, E.S., Graber, M.L., 2008. Overconfidence as a cause of diagnostic error in medicine. The American Journal of Medicine 121 (5, Suppl.), S2–S23.
A. Thomas et al. Cascio, B.M., Wilckens, J.H., Ain, M.C., Toulson, C., Frassica, F.J., 2005. Documentation of acute compartment syndrome at an academic health-care center. The Journal of Bone and Joint Surgery. American Volume 87 (2), 346–350. Cascio, B.M., Pateder, D.B., Farber, A.J., Kramer, D.E., Ain, M.C., Frassica, F.J., 2008. Improvement in documentation of compartment syndrome with a chart insert. Orthopedics 31 (4), 364. Charnley, J., 1950. The Closed Treatment of Common Fractures. Williams and Wilkins, Baltimore. Graber, M., Gordon, R., Franklin, N., 2002. Reducing diagnostic errors in medicine: what’s the goal? Academic medicine : Journal of the Association of American Medical Colleges 77 (10), 981–992. Graber, M.L., Franklin, N., Gordon, R., 2005. Diagnostic error in internal medicine. Archives of Internal Medicine 165 (13), 1493– 1499. Guzzon, D., Brignani, D., Miniussi, C., Marzi, C.A., 2010. Orienting of attention with eye and arrow cues and the effect of overtraining. Acta Psychologica 134 (3), 353–362. Harris, I.A., Kadir, A., Donald, G., 2006. Continuous compartment pressure monitoring for tibia fractures: does it influence outcome? The Journal of Trauma 60 (6), 1330–1335. discussion 1335. Lundin, M., Wiksten, J.P., Perakyla, T., Lindfors, O., Savolainen, H., Skytta, J., et al., 1999. Distal pulse palpation: is it reliable? World Journal of Surgery 23 (3), 252–255. Maher, A.B., Salmond, S.W., Pellino, T.A., 1994. Orthopaedic Nursing. Saunders, Philadelphia. Matsen, F.A., 3rd, Winquist, R.A., Krugmire, R.B., Jr., 1980. Diagnosis and management of compartmental syndromes. The Journal of Bone and Joint Surgery. American Volume 62 (2), 286–291. McRae, R., 1989. Practical Fracture Treatment. Churchill Livingstone, Edinburgh; New York. McRae, R., 1999. Pocketbook of Orthopaedics and Fractures. Churchill Livingstone, Edinburgh; New York. Mubarak, S.J., Owen, C.A., Hargens, A.R., Garetto, L.P., Akeson, W.H., 1978. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. The Journal of Bone and Joint Surgery. American Volume 60 (8), 1091– 1095. Reyna, V.F., Lloyd, F.J., 2006. Physician decision making and cardiac risk: effects of knowledge, risk perception, risk tolerance, and fuzzy processing. Journal of Experimental Psychology. Applied 12 (3), 179–195. Rorabeck, C.H., Macnab, L., 1976. Anterior tibial-compartment syndrome complicating fractures of the shaft of the tibia. The Journal of Bone and Joint Surgery. American Volume 58 (4), 549–550. Salk, E.D., Schriger, D.L., Hubbell, K.A., Schwartz, B.L., 1998. Effect of visual cues, vital signs, and protocols on triage: a prospective randomized crossover trial. Annals of Emergency Medicine 32 (6), 655–664. Schiff, G.D., Hasan, O., Kim, S., Abrams, R., Cosby, K., Lambert, B.L., et al., 2009. Diagnostic error in medicine: analysis of 583 physician-reported errors. Archives of Internal Medicine 169 (20), 1881–1887. Solomon, L., Warwick, D., Nayagam, S., Apley, A.G., 2010. Apley’s System of Orthopaedics and Fractures. Hodder Arnold, London. Talley, O.C., 2010. A Systematic Guide to Physical Diagnosis Clinical Examination. Churchill Livingstone Elsevier. Wall, C.J., Lynch, J., Harris, I.A., Richardson, M.D., Brand, C., Lowe, A.J., et al., 2010. Clinical practice guidelines for the management of acute limb compartment syndrome following trauma. ANZ Journal of Surgery 80 (3), 151– 156.
Improving clinical examination in acute tibial fractures Weiner, G., Styf, J., Nakhostine, M., Gershuni, D.H., 1994. Effect of ankle position and a plaster cast on intramuscular pressure in the human leg. The Journal of Bone and Joint Surgery. American Volume 76 (10), 1476–1481.
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Zagorski, J.B., Latta, L.L., Finnieston, A.R., Zych, G., 1993. Tibial fracture stability. Analysis of external fracture immobilization in anatomic specimens in casts and braces. Clinical Orthopaedics and Related Research 291, 196–207.
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International Journal of Orthopaedic and Trauma Nursing www.elsevier.com/locate/ijotn
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 Alasdair Thomas FRCSEd (Tr & Orth), Dip MSK Med, MRCS, MB ChB (Fellow in Orthopaedic Trauma) a,*, Cheryl Kimber NP (Orthopaedic Nurse Practitioner) a, Donald Bramwell BSc (hons) (Head of Education) b, Ruurd Jaarsma MD, PhD, FRACS (Professor of Orthopaedics, Trauma Surgery) c a
Orthopaedic Department, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia International Musculoskeletal Research Institute, Department of Orthopaedic Surgery, Flinders Medical Centre, Bedford Park, SA 5042, Australia c Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia b
KEYWORDS Clinical examination; Tibial fracture; Visual cues; Backslab; Splint; Dorsalis pedis pulse; Compartment syndrome
Abstract 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 backslab 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).
* Corresponding author. Orthopaedic Department, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia. Tel.: +61 449 510 661; fax: +61 8 8374 0832. E-mail address: [email protected] (A. Thomas). http://dx.doi.org/10.1016/j.ijotn.2015.11.002 1878-1241/© 2015 Elsevier Ltd. All rights reserved.
Improving clinical examination in acute tibial fractures
37
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. © 2015 Elsevier Ltd. All rights reserved.
Editor comments Being able to visualise the skin and palpate pulses is central to the effective assessment and observation of a limb following trauma and/or orthopaedic surgery. Such activity can, however, be significantly restricted by the presence of a splint, a cast or bandages. This study identifies the value of making this practice much easier through the adaptation of the cast and bandages to facilitate assessment. It also demonstrates the importance of balancing the integrity of splints and casts with the need to be able to clearly identify the neurovascular status of the limb. JS-T
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 and Graber, 2008; Graber et al., 2002, 2005; Reyna and Lloyd, 2006). Many clinical examinations also show relatively poor inter- and intraobserver 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, 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.
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 standard orthopaedic textbooks used by junior doctors and nurses were also reviewed. This review showed that there were no articles that explored the potential benefit to the completeness of the clinical examination by exposing the dorsum of the foot of an acutely injured lower limb encased in a splint. Moreover, the general assumption that appeared to be made was that the limb would be suitably exposed to allow a full assessment in all circumstances. As this is not the case in
38 a high proportion of cases that we all come across in day-to-day practice, we felt there was a case to undertake the study and determine whether the dayto-day reality has an effect in undertaking optimum assessment and subsequent care. Back-slab is a term commonly given to a type of splint. It consists of encircling cotton/synthetic padding around an injured limb and then placing a slab of Plaster of Paris or equivalent material onto the padding and holding it in place with bandaging. The term back-slab is a universal term used to describe any type of slab and often is not related to its position on the limb. For this study a back-slab means a posterior slab. Applying a posterior slab to a leg is a relatively simple and quick procedure and is an important step used in the emergency or first aid treatment of fractures and significant soft tissue injuries. Back-slabs are also applied postoperatively after surgical fixation of a fracture or a soft tissue procedure. The design of a ‘traditional’ back-slab for a tibial fracture is based upon the principles that underlie the application of full casts; where the cast extends from the metatarsal phalangeal crease of the great toe to above the knee (Charnley, 1950; Maher et al., 1994; McRae, 1989, 1999). The ankle is routinely placed in a neutral position (the foot 90 degrees to the leg). This is a functional position, so rehabilitation is less hindered should stiffness be an issue on removal of the back-slab. This neutral position is also the optimum position to accommodate increases in compartment pressure (Weiner et al., 1994). Compartment syndrome is a well recognised and potentially devastating complication of an acute tibial fracture (Rorabeck and Macnab, 1976). The diagnosis is primarily a clinical one with intracompartmental pressure measurement providing further evidence of the diagnosis (Harris et al., 2006; Matsen et al., 1980; Mubarak et al., 1978). The clinical diagnostic element makes it a particularly difficult diagnosis to make in unconscious patients when a complete clinically evaluation is not feasible. In the setting of an acute tibial fracture the risk of compartment syndrome is well-recognised and incomplete documentation and evaluation has been previously reported (Cascio et al., 2005). Parameters to be considered should include the tenseness of the compartment in question, pulses, motor examination, sensory examination, pain on passive stretch, paraesthesia and pallor. Importantly, an overall assessment should be clearly documented (Cascio et al., 2005, 2008). Recent literature has proposed clinical practice guidelines and reviewed the literature on compartment syndrome and the importance of a complete
A. Thomas et al. clinical examination continues to be considered vital in the diagnosis (Ali et al., 2014; Wall et al., 2010).
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 Figs. 1 and 2. The nurses were recruited through volunteering during their routine shift in the hospital over a period of 2 days. The simulation took 10 minutes and all nurses approached agreed to take part. The ‘patient’ volunteer was a final year medical student who had been given clear instructions and had practiced displaying the signs and symptoms of compartment syndrome. His briefing included that his injury had been a fractured tibia sustained in a car crash earlier that day for which he had undergone intra-medullary nailing four hours previously. His pain was getting worse and was now worse than when he had sustained the injury and he was pressing his PCA as much as he could, the pain was 9/10 and down to 6/10 just after pressing his PCA, he was aware that movement of his toes increased the pain and that he had altered sensation in the first web space of the dorsum of his foot. The nurses were given the instructions described below. The nurses were blinded to the nature of the
Fig. 1
Traditional backslab.
Improving clinical examination in acute tibial fractures
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Years on acute surgical ward: Years in Orthopaedic nursing: Clinical Entry:
Fig. 2
Cutback design.
study. They were also blinded to the differences in the designs of the back-slabs. The nurses were given the following written brief prior to taking part in the simulation: Thank you for participating in this exercise. It is important that you perform the task as described in the Scenario to the same standard as you would in real life. The observations should be noted as you would enter them into the medical notes, please also fill in the personal information section. As we shall repeat this exercise around the hospital, please do not discuss this project in detail with your colleagues at this time. You are not being assessed personally; we shall be giving group feedback at a later date. Thanks Again. The nurses were given the following scenario verbally and in written format and given the opportunity to clarify the simulation: The patient you are to examine is a post op patient. He underwent nailing of a fractured tibia 4 hours ago. The surgeon has asked for ‘close NV obs’ on the operated leg. The patient has been complaining of increasing pain over the past hour, but this has been controlled with their use of their PCA. Please perform standard clinical observations upon the operated leg, as you feel appropriate in this clinical setting. Underneath the written scenario were the headings listed below. The nurses completed these immediately after finishing their examination on the simulated patient. Position: Years Qualified:
To be able to evaluate the observations undertaken and recorded we constructed a scoring system prior to commencing the study. We used the peerreviewed standard of Cascio et al. in 2005 and 2008. The entries were given one point for each of the parameters reported as being important to be recorded in the situation of a possible compartment syndrome. These were: tenseness of the compartment in question, pulses, motor examination, sensory examination, pain on passive stretch, paraesthesia and pallor and an overall assessment. This gave a scoring system of 0–8 with which the clinical entries were then scored. The scorer was blinded to the type of backslab on which the clinical entry had been made. We considered that the experience and seniority of the nurse examining the patient may be a potential bias and therefore collected and analysed those data as well.
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 nursing between the two groups. There was a significant difference in the quality of the clinical observations recorded in favour of the cut-back group versus the traditional group (Mann– Whitney U Test; Sum of Ranks 311 vs. 154 (p < .005)). There was no significant correlation in the quality of clinical observations in relation to years of experience or years in orthopaedic nursing. Very few nurses recorded whether there was pain on passive stretch, the tenseness of the leg or parathesia, which are all considered cardinal signs of compartment syndrome. Only one nurse, when faced with the traditional assessment, palpated and recorded the presence of a pulse (Table 1).
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 clinical
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Table 1 Backslab type
Table of results. Position Years Years on acute Years in Tenseness Pulses Motor Sensory Pain on Parathesia Pallor Overall Total qualified surgical ward orthopaedic of leg examination examination passive assessment score nursing stretch 4 1 2 1 10 1 7 0.5 4 1 30 0.2 3 25 1 9 4 1.5 0.3 20 4 23 0.01 1.5 3 5 10 2 3 19
1 0.5 2 0.1 10 0.5 7 0.4 2 1 20 0.2 3 15 0.5 0.2 2 1 0.1 10 1 1 0.01 0.3 3 4 10 0.2 1.5 19
0 0 0 0.1 0.1 0 7 0.4 0 0.5 20 0.2 3 15 0.1 0 0 0 0.1 2 0 1 0.01 0.3 3 4 10 0.2 1.5 19
0 0 0 0 1 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0
0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 1 1 1 0 1 1 1 1
0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
EN = Enrolled Nurse, RN = Registered Nurse, CN = Clinical Nurse, CNC = Clinical Nurse Consultant, GN = Graduate Nurse.
0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1
0 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 3 4 4 4 4 4 4 4 4 4 5 5 6 4 4 4 4 5 5 5 5 5 5 5 5 5 6 6 7
A. Thomas et al.
Traditional EN RN RN RN RN RN EN EN RN RN EN GN RN EN Cut back RN EN CN EN GN EN RN EN GN RN RN RN CNC RN RN CN
Improving clinical examination in acute tibial fractures observations. 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’ consequences of injury need to be elicited during a routine examination, i.e. isolated vascular injury, nerve injury and/or venous insufficiency. Given the scenario that prompted our study and the fact that an appropriate examination directed at eliciting compartment syndrome would elicit the other possible clinical entities, we were satisfied that our simulation should prompt a full assessment. Our study showed that, when faced with a clinical scenario designed to simulate a patient developing a clear case of compartment syndrome, very few nurses noted the key clinical findings that would allow the diagnosis to be made. Only 3 noted pain on passive stretch and only 3 noted parathesia. A thorough clinical history and examination are the bedrock of practising safe and effective clinical medicine. In this era of widespread evidence-based medicine, these vitally important skills that we base our day-to-day practice on are difficult to research as they are part of a multifactorial process. Diagnostic error is consistently reported at a 10–15% level. Schiff et al. (2009) reported that physicians recognise that a failure in clinical examination accounted for the diagnostic error in 10% of cases in their study. The role of visual cues is routinely taught throughout clinical medicine. There is an expectation that patients will be appropriately assessed visually as part of any routine clinical examination. The exact role of visual cues within the diagnostic process has not been studied independently, but the role of visual cues (aka visual triggers) in teaching medical students is recognised as a valuable prompt within a problem based learning environment (Azer, 2007). The power of visual prompts and cues within the field of visual perception and orientating has been studied and appropriate cueing items have a powerful effect (Guzzon et al., 2010). The marking of patients is used to identify the correct site for operations and it is now universally recommended that this occurs. In our study, we used a cross to mark an easily palpable dorsalis pedis pulse which led to the pulse being palpated and documented as present 69% of the time in a free-form clinical entry. We could not find any studies that had investigated the power of marking the pulse in relation to its future examination. It could be argued that the pulse should always be palpated when assessing a lower limb in the clinical simulation that we investigated. This was observed to take place
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in our simulation in the cut-back design but it was only documented 69% of the time. The traditional tibial back-slab includes bandaging that creates a barrier to the pulse being palpated. The clinical reality is more likely as in our study where only one nurse felt underneath the bandaging and documented the pulse as present. The palpation of the dorsalis pedis pulse is considered a difficult art to perfect and potentially unreliable (Lundin et al., 1999). However the absence of a dorsalis pedis pulse is clinically significant and should lead to further evaluation. In our institution this would routinely be undertaken with a portable handheld Doppler instrument. With only the toes on display with a traditional design back-slab, capillary refill was routinely recorded in our study as an assessment of ‘pallor’, but this is known to be unreliable and was observed to be performed with an inconsistent method in our study as has been noted in other studies (Anderson et al., 2008). The weaknesses of our study are that we used a clinical simulation and did not observe patient examinations within routine clinical practice. We had to construct our own scoring system based on a published standard as no published validated scoring system exists. We could also have added a third arm were the dorsalis pedis pulse had not been marked. This may have further clarified whether marking the pulse had an independent effect on the scoring system used, rather than just the cutaway design. If we had increased the power in our study we may have detected other statistically significant differences in separate components of the score such as passive stretch or parathesia. On the basis of our study and review of the literature it is our opinion that traditional methods of splinting injured limbs and the teaching and performing of clinical evaluations continue to require critical scrutiny. We would recommend that whenever a splint is used in the treatment of an injured limb, the person applying it should consider: 1. How the splints are providing adequate stability. 2. How they may facilitate and highlight the need for continued clinical vigilance in the monitoring of the limb. As a consequence of our study we have developed a limb observation pro-forma that is used by the nursing staff in our hospital to evaluate and record the status of injured limbs. This highlights the signs and symptoms of compartment syndrome (Appendix S1). We encourage communication between clinical staff that highlights the signs and symptoms of compartment syndrome, at risk patients and the key clinical findings and we now
42 routinely expose the dorsum of the foot and mark the dorsalis pedis pulse.
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.
Appendix: Supplementary material Supplementary data to this article can be found online at doi:10.1016/j.ijotn.2015.11.002.
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