A nurse is teaching a 30-year-old client with a left leg fracture how to use crutches. Which instruction should the nurse provide for going up stairs safely?

When going up stairs, lead with the unaffected leg first for stability, then bring crutches and affected leg together. Other options are unsafe as they put weight on the injured leg or lack balance.

Understanding the "Up with the Good, Down with the Bad" Rule
When ascending stairs with crutches and a non-weight-bearing or partial-weight-bearing lower extremity injury, the core safety principle is to lead with the unaffected (strong) leg. This sequence provides a stable base of support on the higher step before lifting the injured leg and crutches. The mnemonic "Up with the good, down with the bad" helps recall this: the good leg goes up first, and the bad leg goes down first.

Biomechanical Rationale During Stair Ascent
The goal is to minimize force and muscle demand on the injured limb while maintaining balance. In a client with a left leg fracture, the right leg is the unaffected limb. By leading with the right leg onto the step above, the client immediately establishes a stable, single-leg stance on the stronger side. The crutches and the affected left leg are then brought up together to meet the right leg. This method keeps the center of gravity over the stronger leg during the transition, reducing the risk of falls and preventing excessive load on the healing fracture site.

The provided evidence supports the critical relationship between stair climbing and lower limb loading. Research on patients after ankle fracture surgery indicates that even when full weight bearing is allowed, stair climbing demands significant muscle activity and can be affected by residual weakness [1]. Leading with the unaffected leg is a protective strategy that compensates for this potential weakness. Furthermore, studies on joint loading during early rehabilitation demonstrate that specific movement patterns directly influence in vivo joint forces [2]. An incorrect crutch sequence, such as leading with the injured leg, would transmit excessive and potentially harmful loads through the fracture site, which is precisely what postoperative weight-bearing restrictions aim to avoid [3].

Analysis of Incorrect Options
- Option 2 (Lead with the affected left leg): This directly contradicts the safety rule. Placing the injured leg up first forces it to bear the body's full weight during the lifting phase of the unaffected leg, risking pain, loss of balance, and disruption of fracture healing.
- Option 3 (Place both crutches on the step above, then bring both legs up simultaneously): This is a dangerous maneuver. Placing crutches on a higher step while both feet remain below shifts the body's center of gravity forward and upward, creating extreme instability. The axillary crutches are not designed to pull the entire body weight up from a lower level, and this action risks falling backward or losing crutch support.
- Option 4 (Lead with the crutches, then the affected leg, then the unaffected leg): This sequence leaves the body unsupported at a critical moment. After the crutches are placed on the upper step, the client would be leaning forward with no lower extremity support as they attempt to lift the injured leg. This places immense strain on the upper body and creates a significant fall hazard before the strong leg can be positioned. The correct sequence ensures the strong leg provides support before the crutches and injured leg are moved.