Aims. Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines. Methods. This is a national cross-sectional cohort study comprising centres with VFC services across the UK. All consecutive adult patients assessed in VFC in a two-week period pre-lockdown (6 May 2019 to 19 May 2019) and in the same two-week period at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the ‘second wave’ (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected by local investigators for all time periods. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation. Ethics and dissemination. The study results will identify changes in case-mix and numbers of patients managed through VFCs and whether this is safe and associated with patient satisfaction. These data will provide key information for future expert-led consensus on management of trauma injuries through the VFC. The protocol will be disseminated through conferences and peer-reviewed publication. This protocol has been reviewed by the South East Scotland Research Ethics Service and is classified as a multicentre audit. Cite this article: Bone Jt Open 2021;2(3):211–215

Bone and soft tissue sarcoma is an uncommon. Benign swellings are, however, common. An approach to tertiary referral is required to accommodate the need for specialist interpretation of all concerning referrals, while maintaining an acceptable time to diagnosis and management. We aim to describe a new tertiary sarcoma service, utilising modern communication technology and the “virtual clinic” model through a multidisciplinary approach. All suspected musculoskeletal sarcoma cases are discussed, with available history and imaging, in a virtual clinic by a multidisciplinary team within a week of referral. Clinic decisions allow either immediate discharge, progress to further investigation, or clinic appointment. Data from the first thousand patients was prospectively collected for initial management decision, and final intervention, and in 625 for waiting time. Almost one third of patients were discharged from the virtual clinic without physical appointment. 45% were sent for further investigation prior to first clinic appointment. Of 625 patients with referral data, mean waiting time was 5.1 days to virtual clinic. For malignant bone and soft tissue tumours, not requiring neoadjuvant treatment, median time to surgery from virtual clinic review was 37 and 47 days respectively. Through a virtual clinic approach to tertiary sarcoma care, almost a third of referrals have been managed quickly without need for an unnecessary appointment. For 45% of patients the first appointment will be after all necessary investigations have been performed to facilitate rapid decision making. This enables shorter clinic waiting times and rapid transition from first referral to definitive management

Aims. Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results. From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion. A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture. Cite this article: Bone Jt Open 2024;5(2):117–122

Aims. We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function. Methods. All patients managed via this protocol between March and October 2020 were contacted by a medical secretary at a minimum of six months post-injury. The patients were asked to complete the Patient-Rated Wrist Evaluation (PRWE), a satisfaction questionnaire, advise if they had required surgery and/or contacted any health professional, and were also asked for any recommendations on how to improve the service. A review with a hand surgeon was organized if required, and a cost analysis was also conducted. Results. Overall 71/101 patients completed the telephone consultation; no patients required surgery, and the mean and median PRWE scores were 23.9/100 (SD 24.9) and 17.0/100 (interquartile range (IQR) 0 to 40), respectively. Mean patient satisfaction with treatment was 34.3/40 (SD 9.2), and 65 patients (92%) were satisfied or highly satisfied. In total there were 16 contact calls, 12 requests for a consultant review, no formal complaints, and 15 minor adjustment suggestions to improve patient experience. A relationship was found between intra-articular injuries and lower patient satisfaction scores (p = 0.025), however no relationship was found between PRWE scores and the nature of the fracture. Also, no relationship was found between the type of immobilization and the functional outcome or patient satisfaction. Cost analysis of the self-care pathway V traditional pathway showed a cost savings of over £13,500 per year with the new self-care model compared to the traditional model. Conclusion. Our study supports a VFC self-care pathway for patients with minimally displaced distal radius fractures. The pathway provides a good level of patient satisfaction and function. To improve the service, we will make minor amendments to our patient information sheet. Cite this article: Bone Jt Open 2022;3(9):726–732

Stable Weber B fractures are typically treated non-operatively without complications but require close monitoring due to concerns over potential medial deltoid ligament injuries and the risk of delayed talar shift. Following recent evidence suggesting this is unlikely, a functional protocol with early weight bearing was introduced at Glasgow Royal Infirmary (GRI) following a pilot audit. This study aims to evaluate the risk of delayed talar shift in isolated Weber B fractures managed with functional bracing and early weight-bearing, particularly if signs of medial ligament injury are present. We conducted a retrospective review of 148 patients with isolated Weber B fractures without talar shift at presentation that were reviewed at the virtual fracture clinic at our institution between July 2019 and June 2020. The primary outcome was the incidence of delayed talar shift. Secondary outcomes were other complications and adherence to protocol. 48 patients had medial signs present and of these 1 (2%) showed possible talar shift on X-rays at 4 weeks, and was kept under review. This patient had a normal medial clear space at 3 months. No patients with medial signs not documented (n=19) or not present (n=81) had delayed talar shift. 10% of patients (n=15) had at least 1 complication: delayed union (n=2); non-union (n=3); ongoing pain (n=14). Functional bracing with early weight-bearing is a safe, effective protocol for managing isolated Weber B fractures without initial talar shift. This study concludes that the risk of delayed talar shift is low in all patients, with or without medial signs

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

Aims

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.