In 2000 our emergency department implemented a new management for the treatment of isolated, apex volar distal radial fractures involving immobilisation with a wrist splint, written information for carers and no planned follow up. Next day x-ray review acted as a safety net for misdiagnosed or less stable fractures.

This has now been validated with a retrospective review of treatment for distal radial # within the ED.

Patients were identified through the Emergency department’s electronic discharge record. Over a 9 month period 260 patients were identified with metaphyseal distal radial and/or ulna injuries to which a non orthopaedic junior doctor might be expected to apply the Buckle Fracture Algorithm. Of these 161 had isolated distal radial fractures suitable for treatment with a wrist splint. 118 were correctly identified and treated in the ED. 43 patients were sent to # clinic, of these 11 patients were discharged at the 1st visit, however 3 had 3 or more visits and 2 children had additional x-rays. Over this period 9 children were given splints inappropriately according to the protocol, most of these had stable injuries on reviewing the x-rays, 3 were identified and recalled for a cast. None of the children with injuries outside the protocol who were not recalled had an unplanned return with complications.

Taking into account only those children who were correctly managed from the ED the estimated annual cost savings to the NHS for this hospital for this period is £40,784, compared to standard treatment before introduction of this protocol. If all children had been treated according to protocol the estimated cost savings would be £56096/yr.

Introduction: The assessment of bone age using the standard Gruel and Pyle chart based on hand and wrist radiographs is usually carried out by Senior Radiologists. We performed a study to look at both intra and inter observer variability with different grades of clinicians.

Materials and Methods: 30 sets of wrist radiographs were selected at random. The investigators included a Senior Radiographer, a Consultant and Registrar Radiologist an Orthopaedic Consultant and Senior Orthopaedic Fellow.

Discussion: The Radiology team appear to be more consistent in their readings for the assessment of skeletal bone age than the Orthopaedic team. Howevr, it is interesting to note that although the Orthopaedic team are less consistent, when looking at the inter-observer variability, it suggests that both teams are equally well equipped to perform the task.

Conclusion: Our study suggests that we should not cross professional boundaries. Render unto Caeser what is Ceaser’s!

To assess patient/parent satisfaction with treatment of radial Forearm Buckle Fractures without the necessity of fracture clinic visits.

A+E staff were provided with definitions and suitable example X-Rays of radial forearm buckle fractures. The A+E staff were asked to mark the films with a green dot for Radiological review if the patient was included in the study, and these films were seen within 24 hours by a consultant radiologist.

Over a three month period all patients with radial forearm buckle fractures seen in A+E were treated with an Alder Hey splint rather than plaster, they were then given a fracture clinic appointment for three weeks later. At this visit the medical staff completed a proforma with the following information, appropriateness of the diagnosis, side, bone/cortex involved, degree of angulation as well as the mode of injury.

The patients and their parents were asked whether they were happy with the level of support that the splint gave and whether they would have been happy to remove the splint without visiting the fracture clinic.

72 (86.7%) had suffered low energy injuries, 5 (6%) high energy injuries, 5 (6%) did not attend their clinic appointment.

65 of 78 (83%) of parents and 65 of 72 (90%) of patients felt that the level of provided support was adequate (6 patients too young to answer)

58 of 78 (74%) of parents and 53 of 72 (74%) of patients would have been happy to make the decision to remove the splint themselves (6 patients too young to answer)

5 (6%) of the diagnoses were deemed to be inappropriate, of these 2 were picked up in radiology review and sent to clinic and 3 were soft tissue injuries.

We feel that the results show that the majority of patients with radial forearm buckle fractures (appropriate guidelines available to A+E staff) do not need to be seen in the fracture clinic, as long as their X-Rays are reviewed and any inappropriately diagnosed fractures sent to clinic. This has significant implications both for fracture clinic workload and also financially for hospitals.

Previous clinical studies have studied tibiofibular torsion by measuring the angular difference between a proximal (often bicondylar) plane and a distal bimalleolar plane. We measured the angular difference between the proximal and distal posterior tibial planes as defined by ultrasound scans. We found no significant torsional difference between the right and left tibiae of 87 normal children, nor between their different age groups. The mean external torsion of 58 legs with congenital talipes equinovarus was 18 degrees; significantly less than the mean 40 degrees in the normal children and 27 degrees in the clinically normal legs of the 22 patients with unilateral congenital talipes equinovarus. We did not confirm the previously reported increase in external torsion with increasing age. The relative internal tibial torsion we have demonstrated in patients with congenital talipes equinovarus must be differentiated from the posterior displacement of the distal fibula observed by others and which may result from manipulative treatment. The relative internal tibial torsion we found in the clinically normal legs of children with congenital talipes equinovarus is further evidence that in this condition the pathology is not confined to the clinically affected foot.