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BACKGROUND: Optimization of the electronic medical record (EMR) is essential to support the clinician and to improve the quality and efficiency of patient care. The present report describes the development and implementation of a standardized template that is embedded in the EMR and is focused on a comprehensive physical examination during the evaluation of pediatric supracondylar humeral fractures. We compared the completeness of physical examinations as well as the timing of detection and documentation of neurovascular injuries before and after implementation of the template. We hypothesized that the use of a template would increase the completeness of examinations and would lead to earlier documentation of neurovascular injuries. METHODS: A multidisciplinary quality-improvement task force was created to address neurovascular documentation practices for patients who underwent operative treatment of supracondylar humeral fractures. Following a series of formative and process evaluations, a standardized EMR template was implemented. Neurovascular examination documentation practices that were in use before (pre-template group, n = 224) and after (template group, n = 300) the implementation of the template were compared. Logistic regression analyses of the 2 groups were used to compare the likelihood of a complete neurovascular examination and the timing of neurovascular injury identification. RESULTS: There was significant improvement in the documentation of the vascular (odds ratio [OR], 70.7; 95% confidence interval [CI], 39.5 to 126.6; p < 0.0001), motor (OR, 17.6; 95% CI, 9.5 to 32.7; p < 0.0001), and sensory (OR, 23.9; 95% CI, 12.9 to 44.4; p < 0.0001) examinations in the template group. Neurological injuries were more likely to be identified preoperatively in the template group compared with the pre-template group (OR, 6.8; 95% CI, 1.7 to 27.1; p = 0.0067). CONCLUSIONS: The incorporation of a standardized template in the EMR improved the completeness and timing of documentation of neurological injury. Standardized EMR templates developed by a clinically driven multidisciplinary task force have the potential to improve the quality of clinical documentation and to ease communication among providers. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

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BACKGROUND: In contrast to the established principles of "damage-control orthopedics" for temporary external fixation of long bone or pelvic fractures, the "ideal" timing and modality of fixation of unstable spine fractures in severely injured patients remains controversial. METHODS: A prospective cohort study was designed to evaluate the safety and efficacy of a standardized "spine damage-control" (SDC) protocol for the acute management of unstable thoracic and lumbar spine fractures in severely injured patients. A total of 112 consecutive patients with unstable thoracic or lumbar spine fractures and Injury Severity Score (ISS) of greater than 15 were prospectively enrolled in this study from October 1, 2008, to December 31, 2011. Acute posterior spinal fixation within 24 hours was performed in 42 patients (SDC group), and 70 patients underwent definitive operative spine fixation in a delayed fashion ("delayed surgery"[DS] group). Both cohorts were prospectively analyzed for baseline demographics, length of operative time, amount of intraoperative blood loss, total hospital length of stay, number of ventilator-dependent days, and incidence of early postoperative complications. RESULTS: The mean time to initial spine fixation was significantly decreased in the SDC group (8.9 [1.7] hours vs. 98.7 [22.4] hours, p < 0.01). The SDC cohort had a reduced mean length of operative time (2.4 [0.7] hours vs. 3.9 [1.3] hours), length of hospital stay (14.1 [2.9] days vs. 32.6 [7.8] days), and number of ventilator-dependent days (2.2 [1.5] days vs. 9.1 [2.4] days), compared with the DS group (p < 0.05). Furthermore, the complication rate was decreased in the SDC group with regard to wound complications (2.4% vs. 7.1%), urinary tract infections (4.8% vs. 21.4%), pulmonary complications (14.3% vs. 25.7%), and pressure sores (2.4% vs. 8.6%), compared with the DS cohort (p < 0.05). CONCLUSION: A standardized SDC protocol represents a safe and efficient treatment strategy for severely injured patients with associated unstable thoracic or lumbar fractures. LEVEL OF EVIDENCE: Therapeutic study, level III.

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OBJECTIVE: To study the influence of 10 min of cyclic twisting motion on abdominal and back muscle activities. BACKGROUND: Repetitive (cyclic) occupational activity was identified by many epidemiological reports to be a risk factor for the development of work-related musculoskeletal disorders. Biomechanical and physiological confirmation, however, is lacking. METHODS: Trunk muscle electromyography (EMG) was recorded while participants performed a continuous 10-min maximum lumbar cyclic twisting to the left, and maximum isometric twist to the left and right sides was measured before and after the exercise. RESULTS: Abdominal muscles contracted symmetrically, independent of twisting direction. The left posterior muscles' integrated EMG (IEMG) decreased during the exercise, whereas the IEMG of the right posterior muscle increased. Simultaneously with increased antagonist coactivity level of the right posterior muscles after the exercise, decrease in maximal isometric left twisting torque was observed. The abdominal muscles did not exhibit any significant changes during the exercise. After the exercise, the right abdominals demonstrated a significant increase in effort, which was independent of the direction of the maximal effort isometric test. CONCLUSIONS: The change in muscle activity is attributed to neuromuscular compensation for the development of laxity and microdamage in the soft tissue (ligaments, discs, facet capsules, etc.) of the lumbar spine. APPLICATION: The results of this study increase understanding of the risk factors associated with low back disorder induced by labor-intensive occupations that involve cyclic lateral twisting.

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