Introduction. Virtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a cost savings benefit to the NHS. Methods. This project demonstrates the importance of efficient VFC process in reducing the burden on the fracture clinics. We completed preformed a retrospective cross-sectional study, analysing two cycles in May (n=305) and September (n=332) 2021. We reviewed all VFC referrals during this time assessing the quality of the referral, if they went on to require a face to face follow up and who the referring health care professional was. Following the cycle in May we provided ongoing education to A&E staff before re-auditing in September. Results. Between the two cycles there was an average 19% improvement in quality of the referrals, significant reduction in number of inappropriate referrals for soft tissue knee and shoulder injuries from 15.1% (n=50) to 4.5% (n=15) following our intervention. There was an 8% increase in number of fracture clinic appointments to 74.4% (n=247), primarily due to an increase number of referrals from nurse practitioners. Radial head fractures were targeted as one group that were able to be successfully managed in VFC, despite this 64% (n=27) of patients were still seen in the outpatient department following VFC referral. Conclusion. Despite the decrease in the number of inappropriate referrals, and the increase in quality of referrals following our intervention. The percentage of VFC referrals in CAVUHB is still higher than other centres in with established VFCs in England. This possibly highlights the need for further education to emergency staff around describing what injuries are appropriate for referral, specifically soft tissue injuries and radial head fractures. In order to optimise the VFC process and provide further cost savings benefits while reducing the strain on fracture clinics

An osteoporosis screening service for patients presenting to the fracture clinic in Derriford Hospital Plymouth was established in February 2009. We report on the findings of the first year of patients referred for dual energy X-ray absorptiometry (DEXA) screening. Patients between 50 and 75 years of age, who sustained a fracture as a result of a fall from standing height or less, who had not previously had a DEXA scan within the last two years, were referred. Patients outside these age limits with other risk factors for osteoporosis were scanned at the discretion of the fracture clinic consultant. Of those patients who were referred, 96% subsequently attended for a scan timed to coincide with their scheduled fracture clinic follow-up appointment. 402 patients were scanned in total, of which 351 were female and 51 were male. The mean patient age was 65. The results for women were as follows: 21% normal, 45% osteopenic, 34% osteoporotic. The results for men were: 19% normal, 43% osteopenic, 38% osteoporotic. The scan results were forwarded to the patient's general practitioner for action as deemed necessary. These findings support the establishment of this screening service for both men and women

Background. Many Accident and Emergency units employ a “one size fits all” policy with regard to referring patients with musculoskeletal injury for further review in fracture clinic. This may result in inappropriate timings of review in the clinic wasting patient time, clinic time and hospital resources. Aim. Our firm employs a rapid review of all radiographs and A&E notes of all musculoskeletal injury patients referred to our fracture clinic on a weekly basis. We aimed to investigate the impact this review has on the running of our clinic and what benefits were gained. Patients and Methods. Over a three month period all the rapid trauma review meetings were audited with respect to time taken; number of referrals; outcome of referral and staff members present. During this time an audit of the number of patients reviewed in fracture clinic by the Consultant orthopaedic surgeon was also undertaken to allow the average time taken for review of a patient in the clinic to be established. Results and Discussion. Over the three month period 117 patients were reviewed with 44(38%) being given a later appointment; 6(5%) being given an earlier appointment; 8(7%) being discharged to general practice or physiotherapy and 4(3%) being referred to a different clinic. Man time taken to review was 2.4minutes per patient. Mean time for review in fracture clinic was 12.6minutes. Taking the changes to later appointment, discharges and changes to different clinic to be inappropriate referrals, 4.7 occurred per review meeting. This equated to a mean time saved per fracture clinic of 60.6 minutes. Conclusion. This data supports the use of a rapid trauma review meeting to ensure appropriate timing of review of musculoskeletal injury patients. It saves time wasted on inappropriate reviews, saves patient dissatisfaction with being seen unnecessarily and allows patients who should be reviewed more promptly to be identified and reviewed appropriately

Diagnosis of complex regional pain syndrome (CRPS) can be challenging. We explore the role of fracture clinic in diagnosis and management with a closed-loop audit of new guidelines. We retrospectively reviewed patients with CRPS over 3.5 years. We determined the delay from injury to commencement of treatment and monitored symptoms. New guidelines were introduced to fracture clinic in January 2013. The Budapest Criteria aids diagnosis. GAD-7 and PHQ-9 patient questionnaires grade symptoms. Orthopaedic surgeons prescribe nortriptylline or pregabalin, refer to physiotherapy and review patients after six weeks. We re-audited prospectively after implementing these guidelines. The first audit cycle found 11 patients in 3.5 years. The mean delay to anti-neuropathic medication from injury was 4.7 months. Two patients required psychotherapy, one intravenous pamidronate, three inpatient physiotherapy under nerve blocks and two spinal cord stimulators. After implementing guidelines, there were 14 patients with CRPS in 9 months. All but two patients received anti-neuropathic medication on the day of diagnosis. All patients treated appropriately improved markedly within 4–12 weeks. No patients required escalation of treatment. Our guidelines increased pick-up rates of CRPS, diagnoses were made earlier and treatment started sooner. Physiotherapy modalities remained varied, however, early anti-neuropathic treatment led to a rapid improvement in all cases

Current fracture-clinic models, especially in the advent of reductions in junior doctors hours, may limit outpatient trainee education and patient care. We designed a new model of fracture-clinic, involving an initial consultant led case review focused on patient management and trainee education. Prospective outcomes for all new patients attending the redesigned fracture-clinic over a 3-week period in 2010 (n=240) were compared with the traditional clinic in the same period in 2009(n=296). Trainees attending the fracture clinic completed a Likert questionnaire (1 [strongly dissagree] − 5 [strongly agree]) assessing the adequacy of education, support, staff morale & standards of patient care. The percentage of cases given consultant input increased significantly from 33% in 2009 to 84% in 2010 (p< 0.0001), while the proportion of patients requiring physical review by a consultant fell by 21% (p< 0.0001). Return rates were reduced by 14.3% (p< 0.013) & utilization of the nurse lead fracture clinic improved by 10.1% (p< 0.0028). These improvements were most marked in the target group ?StR2 (24.2% & 22.3% respectively). There were significant improvements in staff perception of their education from 2 to 4.75 (p< 0.0001), provision of senior support from 2.38 to 4.5 (p=0.019), morale from 3.68 to 4.13 (p=0.0331) & their overall perception of patient care from 3.25 to 4.5 (p=0.0016). A&E staff found the new style clinic educational, practice changing & that it improved interdisciplinary relations, but did not interfere with their A&E duties. Our model of fracture-clinic redesign has significantly enhanced consultant input into patient care without additional funding. In addition, we have demonstrated increased service efficiency and significant improvements in staff support, morale and education. In the face of current economic and training challenges, we recommend this new model as a tool for enhancing patient and trainee experiences

The increasing rate of fragility fractures in the developed world is now well- documented and presents a significant challenge to Orthopaedics. Although guidelines exist for the management of osteoporosis, both before and after fracture events, little work has yet been done to measure the effect of interventions on reducing the rate of second fractures in the at-risk population. The longitudinal study, begun at The Canberra Hospital, aims to compare rates of second fractures in two populations of patients over 40 years who have sustained a low-impact, minor trauma fracture. A retrospective study of medical records provides baseline information on current intervention rates for osteoporosis. Secondly, a prospective study population is recruited from patients presenting to Fracture Clinic at The Canberra Hospital. Patients presenting to clinic will, after consent, undergo a screening process including blood test and DEXA scans, to confirm or reject a diagnosis of osteoporosis. Those diagnosed will be referred for medical management as well as non-pharmacological interventions. Follow-up will be conducted at 12 months with repeat testing for bone density to determine whether the interventions have produced measurable improvement and patients will be followed up for five years to establish the rate of re-fracture. A progress report will be presented to the conference advising on findings from the retrospective arm, scheduled for completion in September 2009, and results to date of the prospective arm. The study is a current work-in-progress, and will provide a basis for future research in this area

Introduction. Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics. Methods. All patients presenting to the emergency department from 21March 2020 with a musculoskeletal injury or potential musculoskeletal infection deemed to require orthopaedic input were discussed using a secure messaging app. A definitive management plan was communicated by an on-call senior orthopaedic decision-maker. We analyzed the time to decision, if further information was needed, and the referral outcome. An analysis of the orthopaedic referrals for the same period in 2019 was also performed as a comparison. Results. During the study period, 295 patients with mean age of 7.93 years (standard error (SE) 0.24) were reviewed. Of these, 25 (9.8%) were admitted, 17 (5.8%) were advised to return for planned surgical intervention, 105 (35.6%) were referred to a face-to-face fracture clinic, 137 (46.4%) were discharged with no follow-up, and seven (2.4%) were referred to other services. The mean time to decision was 20.14 minutes (SE 1.73). There was a significant difference in the time to decision between patients referred to fracture clinic and patients discharged (mean 25.25 minutes (SE 3.18) vs mean 2.63 (SE 1.42); p < 0.005). There were a total of 295 referrals to the fracture clinic for the same period in 2019 with a further 44 emergency admissions. There was a statistically significant difference in the weekly referrals after being triaged by the VFC (mean 59 (SE 5.15) vs mean 21 (SE 2.17); p < 0.001). Conclusion. The use of an electronic referral pathway to deliver a point of care virtual fracture clinic allowed for efficient use of scarce resources and definitive management plan delivery in a safe manner. Cite this article: Bone Joint Open 2020;1-6:293–301

Abstract. Hospitals during Covid 19 were faced with extreme pressures notably on Emergency Departments. This led to delays in treatment for patients in Trauma and Orthopeadics. In order to support Emergency Departments and improve the service provided, this District General Hospital introduced a Specialty Doctor and Consultant led walk in trauma clinic running on weekdays from 9am-5pm. This abstract focusses on three factors. Firstly the time spent in A&E, secondly the time taken for patients to receive basic radiographic imaging and finally availability of the next fracture clinic appointment. A random sample of 100 patients were selected over a 4 week period prior to introduction of this service and compared with 100 patients since this service began. The average time spent in A&E before this service was 197 minutes which was reduced by 86% by to 27 minutes. The average time taken to receive basic imaging reduced by 18.5% from 81 minutes to 66 minutes. Finally prior to the introduction of these clinics the waiting time of the next fracture clinic varied from 3 to 17 days where as now the patient can be seen by a Consultant in a fracture clinic the next working day. Our findings show the walk in Trauma clinic service has proven to be an invaluable service to this DGH and the NHS. As a result of this service patients are receiving a higher quality of care sooner and a case can be made for the introduction of these clinics throughout the country

Aims. To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS). Methods. A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods. Results. Paediatric trauma admissions across the region fell by 33% (197 vs 132) with a proportional increase to 59% (n = 78) of admissions to the MTC during lockdown compared with 28.4% in 2019 (N = 56). There was a reduction in manipulation under anaesthetic (p = 0.015) and the use of Kirschner wires (K-wires) (p = 0.040) between the two time periods. The median time to surgery remained one day in both (2019 IQR 0 to 2; 2020 IQR 1 to 1). Supracondylar fractures were the most common reason for fracture clinic attendance (17.3%, n = 19) with a proportional increase of 108.4% vs 2019 (2019 n = 20; 2020 n = 19) (p = 0.007). While upper limb injuries and falls from play apparatus, equipment, or height remained the most common indications for admission, there was a reduction in sports injuries (p < 0.001) but an increase in lacerations (p = 0.031). Fracture clinic management changed with 67% (n = 40) of follow-up appointments via telephone and 69% (n = 65) of patients requiring cast immobilization treated with a 3M Soft Cast, enabling self-removal. The safeguarding team saw a 22% reduction in referrals (2019: n = 41, 2020: n = 32). Conclusion. During this viral pandemic, the number of trauma cases decreased with a change in the mechanism of injury, median age of presentation, and an increase in referrals to the regional MTC. Adaptions in standard practice led to fewer MUA, and K-wire procedures being performed, more supracondylar fractures managed through clinic and an increase in the use of removable cast. Cite this article: Bone Joint Open 2020;1-7:424–430

Abstract. Introduction. Clinic letters to the general practitioner (GP) form an essential part of communication in a patient's care. One essential variable requiring 100% compliance is the laterality/side of the diagnosis. Rationale of this audit was to check compliance of the same in clinic letters, to implement changes within the department initially followed by trust wide change in policy to improve the same. Material and Methods. Clinic letters over a period of time were read through in retrospect to see for mention of side. The exclusion criteria were COVID consenting letters over phone, “did not attend” letters and letters for spinal pathology. After 1st limb of audit following actions were taken: doctor education, secretaries to remind the dictating doctor to mention side in the letter and putting up of laminated prompters in all T&O clinic rooms to remind doctors. Following this a 2nd limb was conducted with similar parameters. Results. 1st Limb:. Total letters 271: Fracture clinic- 126. Elective/orthopaedic clinic – 106. Excluded letters– 39. 2nd Limb:. Total letters 169: Fracture clinic- 91. Elective/orthopaedic clinic – 62. Excluded letters– 16. Letters without the mention of side of diagnosis. 1st Limb: Fracture clinic – 28 out of 126 (22.3%). Orthopaedic clinic – 12 out of 106 (11.3%). 2nd Limb: Fracture clinic – 2 out of 91 (2.2%). Orthopaedic clinic – 2 out of 62 (3.2%). Conclusion. With the changes there was an overall compliance of 97.8% in fracture clinic and 96.8% compliance elective clinic dictations

Background. Non-operative cases of mallet finger can be followed up by the hand therapists. Both trust and national policies encourage appropriate indication for follow-up in fracture clinic & cost-effective approach without affecting the patient care. Aims. To reduce unnecessary fracture clinic follow up for Mallet finger injuries. Methods. Management for uncomplicated mallet finger injuries is provided by hand therapy and does not need surgical input. Hand Surgeons in the department agreed to a management protocol for Mallet finger injuries, to streamline patient management and save costs. All Mallet finger injuries less than 6 weeks old not requiring surgery to be referred for hand therapy at the first appointment in fracture clinic and left with an open appointment. Retrospective audit of all patients referred to hand therapy in 2015 (Jan-Dec) done to identify extra appointments. Results. Inclusion criteria: All mallet fingers seen in fracture clinic. Exclusion criteria: > 6-week-old injury at presentation, Patients requiring surgery (joint subluxation). Retrospective first Audit (01/01/2015-31/12/2015):. 55 patients identified fulfilling inclusion criteria. 33 patients had delayed referral to hand therapists (12–107 days). 37 patients had extra fracture clinic appointments totalling 72 appointments. Prospective re-audit (01/10/2016 – 31/12/2016):. 16 patients met inclusion criteria. Number of patients referred in their first fracture clinic: 10 patients. Other 6 patients had mean delay 20 days. Potential cost saving in fracture clinic for the trust over a year of £4730. Extra-fracture clinic in 7 patients, but 3 were clinically indicated (review to check possible subluxation) i.e. only 4 wasted clinic appointments. Conclusions. By restructuring our management for Mallet fingers we have streamlined the service. There is early referral to hand therapy, reduced fracture clinic appointments, decreasing pressure on fracture clinics, enhanced patient experience and cost savings for the trust

Background. Orthopaedic surgeons are increasingly pressured to consider thromboprophylaxis for patients when little evidence exists. The aim of this study was to determine the incidence of fatal pulmonary embolism following office attendance in our outpatient fracture clinic. Methods. Between October 2004 and September 2006 details of all new patients referred to our orthopaedic fracture clinic were prospectively entered into an audit database. Patients did not receive any form of thromboprophylaxis. Data was cross referenced with a national mortality database to identify all patients who subsequently died within 90 days of attendance in fracture clinic. Results. 11,502 new patient fracture clinic appointments occurred during the study period. 5604 patients had lower limb injuries. Twenty three patients died within 90 days of being seen. The mean age of these patients was 75 years (range 52–100). Two of the 23 patients attended fracture clinic with lower limb injuries. Review of the medical records showed no evidence of pulmonary embolism. Assuming a worst case scenario that both died of fatal pulmonary embolism the incidence of fatal pulmonary embolism following attendance in fracture clinic with a lower limb injury is no higher than 0.036% (95% CI 0.09%–0.33%). Conclusion. The incidence of fatal PE following outpatient management of lower limb fractures is very low. This incidence data will inform decisions on the risk-benefit analyisis of thromboprophylaxis in this group of patients

Aims. The COVID-19 pandemic has had a significant impact on the provision of orthopaedic care across the UK. During the pandemic orthopaedic specialist registrars were redeployed to “frontline” specialties occupying non-surgical roles. The impact of the COVID-19 pandemic on orthopaedic training in the UK is unknown. This paper sought to examine the role of orthopaedic trainees during the COVID-19 and the impact of COVID-19 pandemic on postgraduate orthopaedic education. Methods. A 42-point questionnaire was designed, validated, and disseminated via e-mail and an instant-messaging platform. Results. A total of 101 orthopaedic trainees, representing the four nations (Wales, England, Scotland, and Northern Ireland), completed the questionnaire. Overall, 23.1% (23/101) of trainees were redeployed to non-surgical roles. Of these, 73% (17/23) were redeployed to intensive treatment units (ITUs), 13% (3/23) to A/E, and 13%(3/23%) to general medicine. Of the trainees redeployed to ITU 100%, (17/17) received formal induction. Non-deployed or returning trainees had a significant reduction in sessions. In total, 42.9% (42/101) % of trainees were not timetabled into fracture clinic, 53% (53/101) of trainees had one allocated theatre list per week, and 63.8%(64/101) of trainees did not feel they obtained enough experience in the attached subspecialty and preferred repeating this. Overall, 93% (93/101) of respondents attended at least one weekly online webinar, with 79% (79/101) of trainees rating these as useful or very useful, while 95% (95/101) trainees attended online deanery teaching which was rated as more useful than online webinars (p = 0.005). Conclusion. Orthopaedic specialist trainees occupied an important role during the COVID-19 pandemic. COVID-19 has had a significant impact on orthopaedic training. It is imperative this is properly understood to ensure orthopaedic specialist trainees achieve competencies set out in the training curriculum. Cite this article: Bone Joint Open 2020;1-11:676–682

Distal radius fractures are very common and they often require surgical intervention to prevent long-term complications. We noticed that several patients were being managed non-operatively for prolonged periods of time, when ultimately surgical fixation was inevitable. Delayed fixation of these injuries results in prolonged immobilisation, repeat fracture clinic attendances, callous formation, poor soft tissues, stiffness and union. Our aim was to analyse the time to fixation of distal radius fractures at our hospital using a standard volar locking plate. Between December 2010 and September 2011, our study population included all patients who underwent surgical fixation for a distal radius fracture at Royal Derby Hospital. All fractures were fixed using a volar locking plate. Data collected included date of injury, fracture clinic attendances, date listed for surgery and date of surgery. There were 100 patients who underwent surgical fixation, with a mean age of 63.6 years (17 to 91). The mean date from injury to fixation was 7.7 days (range 0 to 23). 82% of fractures were operated on within 14 days, and 98% were fixed within 21 days. We accept that our study does have some limitations; this includes patients who are unwilling to accept surgery at their initial consultation. Distal radius fractures have a strong tendency to revert back to their original configuration; hence we suggest that a decision to operate should ideally be made at the one-week fracture clinic appointment. This avoids the difficulties and complications associated with delayed surgical intervention. Stability, displacement, reduction and patient factors should all be taken into account

Distracted driving is now the number one cause of death among teenagers in the United States of America according to the National Highway Traffic Safety Administration. However, the risks and consequences of driving while distracted spans all ages, gender, and ethnicity. The Distractions on the Road: Injury eValuation in Surgery And FracturE Clinics (DRIVSAFE) Study aimed to examine the prevalence of distracted driving among patients attending hospital-based orthopaedic surgery fracture clinics. We further aimed to explore factors associated with distracted driving. In a large, multi-center prospective observational study, we recruited 1378 adult patients with injuries treated across four clinics (Hamilton, Ontario, Toronto, Ontario, Calgary, Alberta, Halifax, Nova Scotia) across Canada. Eligible patients included those who held a valid driver's license and were able to communicate and understand written english. Patients were administered questions about distracted driving. Data were analyzed with descriptive statistics. Patients average age was 45.8 years old (range 16 – 87), 54.3% male, and 44.6% female (1.1% not disclosed). Of 1361 patients, 1358 self-reported distracted driving (99.8%). Common sources of distractions included talking to passengers (98.7%), outer-vehicle distractions (95.5%), eating/drinking (90.4%), music listening/adjusting the radio (97.6%/93.8%), singing (83.2%), accepting phone calls (65.6%) and daydreaming (61.2%). Seventy-nine patients (6.3%), reported having been stopped by police for using a handheld device in the past. Among 113 drivers who disclosed the cause of their injury as a motor vehicle crash (MVC), 20 of them (17%) acknowledged being distracted at the time of the crash. Of the participants surveyed, 729 reported that during their lifetime they had been the driver in a MVC, with 226 (31.1%) acknowledging they were distracted at the time of the crash. Approximately, 1 in 6 participants in this study had a MVC where they reported to be distracted. Despite the overwhelming knowledge that distracted driving is dangerous and the recognition by participants that it can be dangerous, a staggering amount of drivers engage in distracted driving on a fairly routine basis. This study demonstrates an ongoing need for research and driver education to reduce distracted driving and its devastating consequences

Derriford Hospital gained Major Trauma Centre (MTC) status in April 2012, this led to a significant increase in the trauma case load. Our aim was to review registrar exposure to theatre and clinic in the elective and trauma setting. This was then compared to audits performed pre-MTC status and shortly following MTC changes to see if training standards were being maintained. Improvements in registrar rota planning were made following the previous assessment of training. Training was assessed with respect to national recommendations for registrar training. Data was collected for 8 weeks in February and March 2014 for all 12 registrars, and cross-referenced with the on-call and daily rota. The data was divided into training and non -training registrars. Elective exposure had improved in both theatres and clinic along with trauma theatre exposure whilst fracture clinic exposure had reduced since the previous audit. The reduction may be a result of the on-call registrar no longer being present in fracture clinic when on-call in compliance with MTC guidance. Rota management requires a fine balance between service and training commitments. Recent improvements to the management of the registrar rota appear to provide satisfactory training despite the pressures of MTC changes at Derriford Hospital

Most of current literatures advise on thromboprophylaxis with injectable LMWH for trauma patients. Injectable anticoagulants have got inherent problems of pain, bruising and difficulty in administering the drug, which leads to low compliance. Clexane is derived from a pig's intestinal mucosa, hence could be objectionable to certain proportion of patients because of their religious beliefs. Oral anticoagulants have been used as thromboprophylactic agents in hip and knee arthroplasty. However there is not enough literature supporting their use as thromboprophylactic agent in ambulatory trauma patients with ankle fracture being managed non-operatively as out-patient. This study looks into the efficacy of oral anticoagulant in preventing VTE in ambulatory trauma patients requiring temporary lower limb immobilisation for management of ankle fracture. The end point of this study was symptomatic deep vein thrombosis (either proximal or distal) and pulmonary embolism. Routine assessment with a VTE assessment risk proforma for all patients with temporary lower limb immobilisation following lower limb injury requiring plaster cast is done in the fracture clinic at this university hospital. These patients are categorised as low or high risk for a venous thromboembolic event depending on their risk factor and accordingly started on prophylactic dose of oral anticoagulant (Rivaroxaban - Factor Xa inhibitor). Before the therapy is started these patients have a routing blood check, which includes a full blood count and urea and electrolyte. Therapy is continued for the duration of immobilisation. Bleeding risk assessment is done using a proforma based on NICE guideline CG92. If there is any concern specialist haematologist advice is sought. A total of 200 consecutive patients who presented to the fracture clinic with ankle fracture, which was managed in plaster cast non-operatively, were included in this study. They were followed up for three months following injury. This was done by checking these patients’ radiology report including ultrasound and CT pulmonary scan (CTPA) test on hospital's electronic system. Fracture of the lateral malleolus which include Weber-A, Weber-B and Weber-C fractures were included in the study. Also included were bimalleolar fractures and isolated medial malleolus fractures. Complex pilon fractures, polytrauma and paediatric patients were excluded from the study. Only one case of plaster associated isolated distal deep vein (soleal vein) thrombosis was reported in this patient subgroup. There was no incidence of proximal deep vein thrombosis or pulmonary embolism. No significant bleeding event was reported. Injectable low molecular weight heparin (LMWH) rather than oral anticoagulant has been recommended by most of the studies and guidelines as main thromboprophylactic agent for lower limb trauma patients

We present a complete audit cycle of Emergency Department management of paediatric clavicle fractures at Derriford Hospital. Local guidelines divide the clavicle into three zones. Fractures with minimal displacement in the middle 3/5th heal in the majority of cases without complication and can be discharged without need for follow up, provided parents are adequately educated. An initial audit cycle of 63 cases identified short comings in adherence to the guidelines. These included: Unnecessary fracture clinic follow up of ‘Zone 2’ fractures in 85% and omission of written advice in 86%. The results were circulated, ‘aide memoir’ icons were added to the department's computer coding system, staff teaching sessions were organised and a patient advice sheet was produced. Following the implementation of changes, a 23 case re-audit showed fewer unnecessary referrals to fracture clinic (17% vs. 85%) and improvements in the number of parents being given written advice (43% vs. 14%). Staff training, provision of information leaflets and changes to the ED coding system dramatically improved the adherence to hospital guidance. This resulted in standardisation of care, fewer unnecessary appointments and cost savings to the trust. Following this audit, a telephone survey was completed to assess parent's satisfaction with their treatment

An audit was carried out to assess the management of patients with fragility fractures in fracture clinic and primary care. NICE guidelines advise these patients require treatment for osteoporosis if 75 years or older, and a DEXA scan if below this age. Distal radius and proximal humeral fractures were identified in a retrospective review of letters from 10 fracture clinics. Current medication of all patients ≥ 75 years was accessed and DEXA scan requests identified for patients < 75 years. There were 69 fragility fractures: 53 distal radius and 16 proximal humerus. 4 letters (6%) mentioned fragility fracture and advised treatment and 3 (3%) correctly advised a DEXA scan. Only 3 of 25 (10%) patients ≥ 75yrs not previously on osteoporosis medication had treatment started by their GPs. 3 of a possible 29 (10%) patients < 75 years were referred for a DEXA scan. A text box highlighting fragility fractures and NICE guidelines was added to all clinic letters for patient ≥ 50 years old. Re-audits showed an improvement in management of these fractures, with 45% of patients ≥ 75 years being started on treatment and 39% of patients < 75 years being referred for a DEXA scan

We completed a retrospective case study of 66 consecutive isolated closed 5. th. metacarpal neck fractures that presented to our Hospital between September 2009 and March 2010. Their management was established by referring to outpatient letters and A&E notes. The aim of the study was to establish if it would be more efficient and cost effective for these patients to be managed in A&E review clinic without compromising patient care. Of these 66 patients, 56 were males and the mean age was 26 years (12–88 years). Four fractures were not followed up at our Trust, six did not attend their outpatient appointment, one did not require follow up. Of the remaining 55, reviewed at a fracture clinic, all but two were managed conservatively, with 47% requiring one outpatient appointment only. The cost of a new patient Orthopaedic outpatient appointment is £180 with subsequent follow up appointments costing £80 per visit, in contrast to an A&E review clinic appointment at a cost of £60. In view of the small percentage in need of surgical intervention: we highlight the possibility for these patients to be managed solely in the A&E department with a management plan made at the A&E review clinic with an option to refer patients if necessary, and the provision of management guidelines and care quality assurance measures. This, we believe, would maintain care quality for these patients, improve efficiency of fracture clinics and decrease cost. We calculate that even if only all the patients that required one follow up appointment could have been managed by A&E alone then the saving to the local health commissioning body over a six month period from within our trust alone, would have been £3000, which across all trusts providing acute trauma services within the NHS would amount to a substantial saving nationwide