Weber A fractures are a sub-group of ankle fractures parallel or distal to the joint line, below the level of the syndesmosis. Most stable Weber A fractures are managed conservatively with no significant difference in outcome vs. surgical intervention.^1,2In an effort to ensure staff time was being used as efficiently as possible, a consultant-led virtual fracture clinic (VFC) was introduced to manage Weber A fractures. Patients not requiring immediate surgery were reviewed remotely and, wherever possible, were ‘virtually discharged’ to a nurse-led telephone line. Those with diagnostic uncertainty, unusual features or delayed recovery received a face to face review from a nurse or surgeon.

To examine how patients were allocated under this protocol, along with overall patient satisfaction and functional outcome.

An audit of satisfaction and outcome was performed of all patients who presented with a Weber A fracture to the ED between October 2011 and October 2012. The minimum follow-up period was two years. A satisfaction and patient reported outcome (5-level-likert-scale, EQ-5D, MOXFQ) measure was conducted via telephone.^3,4After exclusions, 79 patients were left, of which 63 were successfully contacted (80%).

Of the 79 patients included, 33 (42%) required early face-to-face review while 46 (58%) were discharged with advice following discussion at the VFC. Of the 63 successfully contacted, receipt of the information leaflet was recalled by 61 (97%) and 54 (86%) were satisfied with the information they had received. There was no difference in patient satisfaction regarding recovery (p=0.079) or treatment information (p=0.236) provided between avulsion and transverse fractures or in functional outcome according to MOXFQ (p=0.626) or EQ-Vas (p=0.915) scores.

Patient satisfaction can remain high without face-to-face consultations following injury. This was demonstrated by the high satisfaction with recovery (83%) and with information provided (86%) and is consistent with current published literature and similar to what would have been achieved with traditional fracture clinic review.⁵The new protocol reduces unnecessary hospital attendances for patients and reduces the burden of unnecessary review in orthopaedic departments. Only 15% of patients required review at a traditional fracture clinic and 27% at a nurse-led clinic, freeing resources for more complex cases.

Objectives

“Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway.

Primary bony tumours of the elbow account for approximately 1% of all osseous tumours. The delayed diagnosis is commonly reported in the literature as a result of lack of clinician familiarity. We present the largest series of primary bone tumours of the elbow in the English literature.

We sought to identify characteristics specific to primary elbow tumours and compare these to the current literature. We discuss cases of misdiagnosis and reasons for any delay in diagnosis. The authors also recommend a collaborative protocol for the diagnosis and management of these rare tumours.

A prospectively collected national database of all bone tumours is maintained by an independent clerk. The registry and case notes were retrospectively reviewed from January 1954 until June 2013. Eighty cases of primary osseous elbow tumours were studied. Tumours were classified as benign or malignant and then graded according to the Enneking spectrum.

There were no benign latent cases in this series. All cases in this series required surgical intervention. These cases presented with persistent rest pain, with or without swelling. The distal humerus was responsible for the majority and most aggressive of cases. The multidisciplinary approach at a specialist centre is integral to management. Misdiagnosis was evident in 12.5 % of all cases. Malignant tumours carried a 5-year mortality of 61%. Benign tumours exhibited a 19% recurrence rate and in particular, giant cell tumour was very aggressive. The evolution in treatment modalities has clearly benefited patients.

Clinicians should be aware that elbow tumours can be initially misdiagnosed as soft tissue injuries or cysts. The suspicion of a tumour should be raised in the patient with unremitting, unexplained non-mechanical bony elbow pain. We suggest an investigatory and treatment protocol to avoid a delay to diagnosis. With high rates of local recurrence, we recommend regular postoperative reviews.

Fifth metatarsal fractures are common and the majority unite regardless of treatment. A sub-type of these fractures carries a risk of non-union and for this reason many centres follow up all 5^th metatarsal fractures. In 2011, a standardised protocol was introduced to promote weight-bearing as pain allowed with a tubigrip or Velcro boot according to symptoms. No routine fracture clinic appointments were made from A&E but patients were provided with information and a help-line number to access care if required. Some patients still attended fracture clinics, but only after review of their notes/X-rays by an Orthopaedic Consultant, or after self-reported “failure to progress” using the special help-line number.

Audit of a year prior to the introduction of the protocol and the year following it was performed. All x-rays taken at presentation in A&E were reviewed and classified independently (KBF/JM) for validation.

During 2009/2010, 279 patients presented to A&E with a 5^th metatarsal fracture and were referred to a fracture clinic. 106(38%) attended 1 appointment, 130(47%) attended 2 appointments and 31 (11%) attended 3 or more appointments – 491 appointments in total. 3% failed to attend the clinic. Operative fixation was performed in 3 patients (1.07%).

In 2011/2012, of 339 A&E fractures, only 63 (19%) attended fracture clinic. 37 (11%) attended 1 appointment, 12 (4%) 2 and 9 (3%) 3 or more appointments – 96 appointments in total. Four patients (1.17%) required operative fixation.

Our study did not demonstrate any added value for routine outpatient follow-up of 5^th metatarsal fractures. Patients can be safely allowed to weight bear and discharged at the time of initial presentation in the A&E department if they are provided with appropriate information and access to a “help line” run by experienced fracture clinic staff. The result is a more efficient, patient-centred service.

Intervention is rare following minimally displaced radial head fractures or positive elbow ‘fat pad’ signs. A pilot study (n=20) found no patient required active treatment after discharge following their first fracture clinic visit. We therefore initiated routine discharge from A&E with an advice sheet, and an ‘open-door policy’ if patients failed to progress.

51 patients were managed by A&E according to this protocol over a six-month period. A standardised assessment of symptoms, satisfaction and functional limitation was completed for 24 patients by phone; average time to follow-up 4.2 months (range 2–9 months). Fourteen (58.4%) reported no pain. The 10 patients (41.6%) with on-going pain reported a median visual analogue score (VAS 0–10) of 0.7 (0–4) at rest, 0.25 (0–4) at night, 3.0 (0–10) carrying heavy objects and 2.75 (0–10) during repetitive movement. 4 of 24 (16.7%) reported minor functional impairment. 3 of 24 (12.5%) patients requested orthopaedic review, but all were satisfied with outcome, seeking reassurance and discharged without any intervention. 3 of 24 (12.5%) were unhappy with their progress, but all had suffered from chronic pain or psychological conditions predating their injury. When offered further review, none of these patients accepted.

22 (91%) were satisfied with their treatment and 23 (95.8%) returned to work and hobbies. This data suggests routine discharge from A&E with advice does not compromise care, as no intervention is usually required beyond advice. These findings have obvious positive clinical and financial implications in streamlining clinical workload.

The aim of management of an adult distal humeral fracture is to restore mobility, stability and pain-free elbow function. Good results are usually achieved in the majority of fractures treated with ORIF, but the management of comminuted fractures in elderly, frail patients with osteoporotic bone remains controversial. The literature focuses on elbow replacement if stable internal fixation cannot be achieved, with “bag-of-bones” management now rarely discussed eg. key-note paper - 10 successful cases reported by Brown RF & Morgan RG in 1971 (JBJS 53-B(3):425-428). We present the experience in two units in which conservative management has been actively adopted in selected cases by consultants with a subspecialty interest in the elbow.

All patients over the age of 60 with distal humeral fractures (2007 – 2009) who had been treated conservatively were reviewed clinically and radiologically. Duration of follow-up and outcome, including the Oxford and quick DASH scores, were recorded, with the fractures classified using the AO system.

There were 25 patients, 19 female and 6 male. 19/25 patients have been successfully treated conservatively with a mean Range Of Movement: Extension/Flexion: 45/125, Pronation/Supination 74/70. Only 5 underwent subsequent total elbow replacement and one delayed ORIF. There is a significant complication rate following surgical treatment with ORIF or elbow replacement in elderly, frail patients, including infection, painful non-union and/or stiffness. We believe that there is a role for initial conservative treatment in selected patients with low, displaced, comminuted humeral fractures in osteoporotic bone. Initial early mobilisation as pain allows can give good functional results without the risks of operation. It does not preclude future surgery if conservative treatment fails, but this is not required in the majority of cases.