Neurovascular status documentation in patients with open tibial and fibular fractures - Hani Abdul-Jabar and Amir Sadri March 2009

Neurovascular status documentation in patients with open tibial and fibular fractures requiring soft-tissue cover

 

Hani Basil Abdul-Jabar - ST2 in Plastics Surgery, St Georges Hospital - London

Amir Sadri - FY2 in Trauma and Orthopaedics, The Hillingdon Hospital - London

Introduction:

This is a re-audit of a similar previous audit completed in 2006 which assessed the neurovascular (NV) status of patients with open tibial and fibular fractures. The previous audit examined 50 patient case-notes over a three-year period (Jan 03-Jan 06), and found that a complete and clear documentation was only made in 7 of the patients (14%).

 

Why is it Important?

NV status ranks highly amongst the various trauma scoring systems used in trauma centres worldwide (MESS, NISSSA, HFS-78, etc), and several studies have shown correlations between the initial severity of an injury and the patient's eventual physiological and psychosocial future outcomes.

Current guidelines for the management of patients with open tibial and fibular fractures following lower limb trauma, published in the joint report by the BOA and BAPS released in 1997, clearly emphasise the importance of clear and complete initial documentation of the NV status, as it aids in early decision making.

Signs of Neurovascular Compromise:

Vascular insufficiency within the lower limb can only be fully evaluated once both hypovolemia and limb deformity have been corrected. The main five vascular parameters which should be assessed following a lower limb trauma are the:

 

1)       Temperature

2)       Colour / Perfusion

3)       Capillary Refill Time

4)       Dorsalis Pedis Pulse

5)       Posterior Tibial Pulse

 

The presence or absence of the above pulses can be either checked manually or with the use of a hand held Doppler device.

Signs of a sensory loss or abnormal sensation are far more specific in the initial assessment, as sensory damage occurs much sooner than does loss of motor function. The five main nerves which are prone to injury following lower limb trauma are the:

 

1)       Saphenous Nerve

2)       Sural Nerve

3)       Tibial Nerve

4)       Deep Peroneal Nerve

5)       Superficial Peroneal Nerve

Method:

A retrospective analysis was made of 30 patient case-notes over a two-year period (Jan 07 - Jan 09), all of which were extracted using the ICD coding system.

 

A scoring sheet (with a total score of 10 for each set of   case-notes) was designed to collate any written documentation of the five vascular parameters and sensory presence/absence of the five main nerves involved.

 

During initial hospital admission all the patients had been assessed by three different specialities:

 

1)       Accident and Emergency (A&E) / Casualty junior doctors

2)       Trauma and Orthopaedics (T&O) junior doctors

3)       Plastics junior doctors

 

The Plastics team were most involved in the care of these patients as all 30 patients required soft-tissue cover following primary bony fixation.

Demographics of Data:

The series consisted of 24 males (mean age 31, range 13-47) and 6 females (mean age 37; range 28-59). All females had isolated injuries, while 8 males had polytrauma.

Results:

Percentage documentation for each of the vascular and neurological parameters across the three specialities can be summarised in the table below.   

Neurovascular Status

A&E

T&O

Plastics

Colour

15%

15%

47%

Temperature

35%

35%

63%

Capillary refill

95%

90%

100%

Dorsalis Pedis Pulse

65%

90%

90%

Posterior Tibia Pulse

65%

85%

93%

Sural Nerve

10%

35%

30%

Saphenous Nerve

40%

95%

77%

Tibial Nerve

15%

5%

40%

Superficial Peroneal Nerve

80%

95%

93%

Deep Peroneal Nerve

55%

30%

67%

The overall compliance based on a score of 10 was as follows:

Compliance

A&E

T&O

Plastics

Min

1

2

3

Max

7

7

9

Average

4.75

5.75

6.5

Conclusion:

Documentation was poor across all three specialities but was worst amongst A+E junior doctors, this can be explained by a number of possible factors:

1)       A+E has the most junior staff members

2)       A+E is mostly staffed by non-surgical trainees

3)       There is a time-limit for patient management (4 hour-rule in UK hospitals)

4)       The A&E trauma chart has no diagrammatic illustrations of the peripheral nerves and vessels

Recommendations:

1)       To amend the current trauma chart used widely throughout UK hospitals; adding a clear diagrammatic illustration of the peripheral nerves and vessels.

2)       To add a scoring sheet for lower limb trauma, to the currently used trauma chart.

3)       To produce demonstration charts illustrating the neurovascular supply of the lower limb and have these charts clearly visible in clinical areas.

4)       To produce ID-sized two-sided Demo charts, to be handed to juniors within the three main specialities at their hospital induction.

5)       To perform a re-audit in two years, once these measures have been introduced.



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