Julie Santy-Tomlinson
University of Manchester
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International Journal of Orthopaedic and Trauma Nursing | 2016
Julie Santy-Tomlinson; Louise Brent
In 2008 Nobo Komagata broke his hip. In his blog about his experiences (Komagata 2008) he tells us: “I thought that the fracture would heal in three months and that I would be able to resumemy normal life after that. But it was not at all like that. I had to go through a lot more than I anticipated in terms of treatment and also psychologically.[. . .] Once I regained the mobility, it’s easy to forget what I went through. However, I often look back and feel that even the ability to walk is such a great gift. I once accepted the possibility of not being able to walk on my own for the rest of my life. As I can walk again, I should use the gift appropriately”. There are several different types of fractures sustained due to bone fragility, but hip fracture is perceived to have the most lasting impact on the lives of individuals. Not everyone is able to walk on their own again after hip fracture – a much feared cause of loss of mobility and independence for older people. In developing countries people frequently die or become disabled following road traffic trauma. In developed countries death or loss of independencemore frequently occurs following fragility fracture. As global societies progress, this may become more balanced – bone fragility is associated with social conditions and lifestyle in wealthier nations and the link between fracture and osteoporosis is more pronounced in the developed nations in the northern hemisphere – for now. At a global level, the figures are already staggering. A fragility fracture is estimated to occur every 3 seconds. This amounts to 25,000 fractures per day or 9 million per year. The financial costs are also immense; 32 billion EUR per year in Europe and 20 billion USD in the United States. The potential burden imposed on growing economies is another source of concern. As the population of China ages, the cost of hip fracture care there is likely to reach 1.25 billion USD by 2020 and 265 billion by 2050. Similar projections are being made for other parts of the world where there are ageing populations and increasingly sedentary lifestyles as social conditions change (International Osteoporosis Foundation, 2016). Fragility fractures are predictable – we know what causes them and we know, at least to some degree, how to prevent them. However, unlike many other serious health problems such as cardiovascular disease and cancer, the incidence of osteoporosis is not decreasing and neither is the rate of falls in older people. Hence, fragility fracture is one of the foremost challenges for health care providers, commissioners and funders in all parts of the world as 2020 and 2050 rapidly approach. Just as we advise patients against smoking or obesity, there is a need to mobilise all health care workers, health organisations and governments to address bone health, falls and fractures. The impact of each one of those expected 9 million hip fractures is significant pain, disability, reduced quality of life, loss of independence and decreased life expectancy. Those wrist, arm and spinal fractures seen every day are warning signs that a hip fracture may just be a matter of time. Prevention of bone fragility has to be the starting point – beginning by working with families, schools and children’s services to ensure that children and young people reach their peak potential bone mass before depletion begins in adulthood. This may well be the toughest challenge of all. The factors that affect bone mass in childhood and early adulthood are complex and include numerous hormonal, hereditary and lifestyle influences. One of the most pressing problems is that children and young people, International Journal of Orthopaedic and Trauma Nursing (2016) ■■, ■■–■■ ARTICLE IN PRESS
Archive | 2018
Julie Santy-Tomlinson; Robyn Speerin; Karen Hertz; Ana Cruz Tochon-Laruaz; Marsha van Oostwaard
The most common cause of fractures in the elderly is falling, usually from standing height, and falling is the leading cause of hospitalisation due to accidental injury, with significant risk of death in the following year due to complications [1]. Low bone density due to osteoporosis or osteopenia means that falls easily result in fractures, even when the fall dynamics are relatively mild, as discussed in Chap. 1. These are often referred to as ‘fragility’, ‘osteoporotic’ or ‘minimal trauma’ fractures and most commonly occur in those over the age of 50 years [2], the same population at risk of osteoporosis.
Archive | 2018
Ami Hommel; Julie Santy-Tomlinson
The management of wounds and the prevention of pressure injuries (also known as pressure ulcers) are fundamental aspects of the management of the patient following fragility fracture, especially following hip fracture and associated surgery. Ageing skin and multiple comorbidities are significant factors in skin injury and wound healing problems. The aim of this chapter is to provide the reader with an overview of evidence-based approaches to the prevention of pressure injuries and to wound management following hip fracture surgery.
Archive | 2018
Louise Brent; Julie Santy-Tomlinson; Karen Hertz
The involvement of families, friends and others important to the patient has always been central in person-centred, individualised care. Following fragility fracture, many patients wish for their family and significant others to be involved in their care, both during the hospital stay and following discharge, and it is often expected that families will provide, or lead, continuing care once they are discharged.
Injury-international Journal of The Care of The Injured | 2018
Louise Brent; Ami Hommel; Ann Butler Maher; Karen Hertz; Anita Meehan; Julie Santy-Tomlinson
The challenge of caring for patients with fragility fractures is particularly acute for nursing teams who are in short supply and work with patients following fracture on a 24 h basis, coordinating as well as providing complex care. This paper considers the role of nurses within the orthogeriatric team and highlights the value of effective nursing care in patient outcomes. It explores the nature of nursing for patients with fragility fracture with a focus on the provision of safe and effective care and the coordination of care across the interdisciplinary team. It also highlights the need for specific skills in orthopaedic and geriatric nursing as well as specialist education.
Nursing Standard | 2017
Emma Limbert; Julie Santy-Tomlinson
Acute limb compartment syndrome (ALCS) is a serious complication of traumatic injury. Although ALCS can occur in any limb, it most commonly occurs following injury to the lower leg, particularly in fractures of the tibia. Practitioners should recognise and treat ALCS as early as possible to prevent the development of further, potentially serious, complications. Most of the literature recommends that patients at risk of ALCS should be carefully monitored, with a focus on pain as the main symptom. However, patients in the intensive care unit (ICU) who are unconscious or sedated may be unable to report pain or are unreliable in doing so, therefore it is necessary to consider alternative assessments for ALCS. This article provides an overview of the evidence and guidelines in relation to ALCS in the lower leg and how to undertake an effective assessment for the condition in patients in the ICU. This will enable practitioners to make evidence-based clinical decisions to improve practice and patient safety.
International Journal of Orthopaedic and Trauma Nursing | 2017
Julie Santy-Tomlinson
The aim of this special issue is to highlight some of the existing and emergent evidence, approaches and ways of thinking needed to make progress within fragility fracture care. Clinicians with an interest in fragility fracture worldwide are united in aiming to reduce the impact of fragility fracture. They now work alongside the Fragility Fracture Network (FFN http://fragilityfracturenetwork. org/), an organisation whose mission is to “optimise globally the multidisciplinary management of the patient with a fragility fracture, including secondary prevention”. The FFNs annual congress is taking place in Malmo, Sweden (http://fragilityfracturenetwork.org/ourorganisation/6th-ffn-global-congress-2017/) at about the time this issue of the International Journal of Orthopaedic and Trauma Nursing is published. There are many priorities within the 6 themes of the FFN; perioperative care, surgical treatment, rehabilitation, secondary prevention, research and education and changing healthcare policy. Some of these themes are represented in this special issue, others are less evident. Fragility fractures occur as a result of ‘low energy’ trauma, often from a fall from standing height or less, that would not normally result in a fracture (Kanis et al., 2001). The causes of fracture are complex but the headline is the combination of a fall and fragile bone due to osteoporosis. Hip fractures are a major challenge for health care services because of the associated high rates of disability, complications and mortality. For practitioners working in acute orthopaedic and trauma settings there are two central priorities; (1) ensuring that care following fragility fracture results in the best possible patient outcomes and (2) that the fracture is treated as a warning so that the opportunity is taken to prevent the second fracture and beyond; “As with all fragility fractures, an essential part of the management of the acute fracture episode is a systematic attempt to prevent another fracture, by addressing osteoporosis and falls risk” (Falaschi and Marsh, 2017 p.vi). When the call for papers for this special issue was published (Santy-Tomlinson and Brent, 2016), we had hoped to receive a range of submissions relating to various different aspects of fragility fracture prevention, interdisciplinary management and care. In fact, we received an excellent body of papers focussed almost entirely on the acute hospital care and management of the patient with a hip fracture. This is, in part, understandable since the majority of orthopaedic and trauma practitioners work in acute hospital settings. However, it is important that this special issue is comprehensive enough to enable readers to have the salient issues clearly in their minds as they read each paper. To place the other
International Journal of Orthopaedic and Trauma Nursing | 2017
Julie Santy-Tomlinson
Although traction has been used for at least two millennia for the management of skeletal injury and deformity, many traction systems and devices were developed in the 19th Century. The aim of traction as a method of treatment has always been to immobilise and rest a limb or reduce a fracture through the application of pulling forces exerted through apparatus attached to the limb. The names of those who developed such systems and apparatus such as Buck, Russell, Steinmann, Kirschner and Pearson were frequently spoken daily in orthopaedic departments in the 20th century (Pelter, 1968). These days traction is commonly considered an outmoded form of treatment for musculoskeletal conditions. It is, however, very far from a purely historical entity and remains an important part of modern orthopaedic care. Every time I ask a group of orthopaedic nurses when they last cared for a patient with some form of orthopaedic traction, their response is often either; “Oh we have a patient with traction right now. . .” or “. . . within the last few weeks”, indicating that traction is still in regular use, if considerably less so than in, say, the 1960s. The practice of surgical fixation of fractures has, indeed, led to a greatly reduced prevalence of traction, but there are still times when it remains an intervention of choice; be it manual, skin or skeletal. Examples are provided when a 6-year-old child sustains a fracture of the femoral shaft or an older person, perceived too frail for surgery, sustains a fracture of the femoral condyles and ‘conservative’ management with traction proves the best option. The perception that traction has been all but phased out leaves orthopaedic practitioners with a problem that is compounded by a decrease in the availability of specialist orthopaedic nursing education. The practice of applying and caring for patients in traction is now rarely taught. A very experienced orthopaedic nurse I know who works as a nurse practitioner in a clinic/outpatient setting is regularly called ‘up to the wards’ to ‘sort out’ some traction apparatus or other because she is perceived as ‘of the old school’ and in possession of skills beyond the scope of many of her more recently graduated colleagues. For the patient who is being cared for by a team of nurses without the skills to ensure that traction is effective and safe, this is a source of considerable danger and worry. The Thomas’ splint is a case in point; it has been around since the latter half of the 19th century and is still used in the acute management of some fractures in both children and adults (Robinson and O’Meara, 2009). Although it has been redesigned to some degree over the last few decades, it remains, fundamentally, a padded metal ring attached to metal rods that provide a resting splint and a device through which to channel traction forces that push the padded ring into the patient’s groin whilst pulling the limb in the opposite direction; hence, providing traction and counter-traction at the same time without the need for other devices such as beams, cords, weights and pulleys. The presence of the ring and its associated forces around the patient’s groin and gluteal fold results, not only in traction, but in pressure, shear, friction and moisture — the extrinsic forces known to result in pressure ulcers. Hence the Thomas’ splint, new or old version, risks an assault to the patient’s skin integrity, potentially resulting in tissue injury in both adults and children. The risk of skin damage is significantly increased if the splint does not fit correctly, so the measuring and fitting of the device should only be undertaken by those with appropriate knowledge and skills. Even though there is no research that has explored this problem and potential solutions, orthopaedic practitioners who care for any patient with a Thomas’ splint should know that the skin under the ring needs to be checked several times a day, kept clean and International Journal of Orthopaedic and Trauma Nursing (2016) ■■, ■■–■■ ARTICLE IN PRESS
International Journal of Orthopaedic and Trauma Nursing | 2015
Julie Santy-Tomlinson
Orthopaedic practitioners are more likely to read and subscribe to a journal that specifically serves their specialty. The aims of this journal include the publication of “. . .a wide range of papers from primary research and evidence updates to personal reflections on practice, education and management issues” with an explicit focus on the person with musculoskeletal problems. Without specialist journals such as this one, researchers who have conducted studies relevant to orthopaedic and trauma nursing care would only be able to publish their research in general nursing journals – less likely to be read by those engaged in the care of the orthopaedic patient and in a position to put that research into practice. Berthelsen and Holge-Hzelton’s (2015) study of orthopaedic nurses’ attitudes towards clinical nursing research demonstrated that more than three-quarters of the nurses in their survey “. . . indicated an interest in nursing research and high motivation in improving their theoretical and practical knowledge. They were also convinced that research ought to be a central part of their daily practice”. What they probably mean by research being a central part of practice was the important step of implementing research rather than conducting it. The body of research that acts as a foundation for nursing care has burgeoned in the last 30 years. It has become an integral part of nursing education curricula and the notion of evidence based practice is now embedded in the language of nursing and, to some degree, integrated into the practice of nursing care itself. Research in orthopaedic and trauma nursing, however, is not so prolific. When compared to, for example, wound care, cardiac care or oncology nursing research the body of work on which to draw seems almost miniscule. An exploration of the accuracy of the previous statement and a discussion of the reasons for it are worthy of considerable discussion, but for the purposes of this short editorial it seems fitting to focus on one underlying issue – who should take responsibility doing the research that will develop and expand the evidence base for orthopaedic and trauma nursing practice? Of course, the obvious answer is all of us – every practitioner, manager, educator and researcher (and even journal editor) must take some responsibility because the research cycle begins with research problems that are derived from important practice issues and ends with dissemination and implementation in practice. But we should concentrate, on this occasion, on the bit in the middle – the conduct of research studies that are centred on those important practice problems that affect patients and those caring for them. Whose job is it to ‘do’ this research? Some of the answers to this question lie in the material to be found in this very journal. Published in this issue of the International Journal of Orthopaedic and Trauma Nursing, or waiting in the wings for publication in the next issue or two, are papers focussing on a wide variety of topics including: preoperative education before total knee replacement, physical health problems experienced postoperatively following total knee replacement, wound drain management following arthroplasty, personcentred hip fracture care, bowel management following joint arthroplasty, co-managed care following hip fracture, quality of life and functional status following arthroplasty, nursing implications of fasttrack arthroplasty surgery and orthopaedic nurses’ attitudes towards clinical nursing research. This list represents a range of issues which really matter to International Journal of Orthopaedic and Trauma Nursing (2015) 19, 1–2
International Journal of Orthopaedic and Trauma Nursing | 2017
Julie Santy-Tomlinson