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EDITORIAL

Fracture Clinic- Current Practice and Future Trends

Muhammad Adeel Akhtar, Christopher W Oliver

*Royal Infirmary of Edinburgh, United Kingdom.

Address for Correspondence:

E Mail: m_adeel_akhtar@yahoo.com

 

Abstract

Background: Edinburgh Orthopaedic Trauma Unit is a tertiary referral centre for south-east of Scotland. An Audit to determine the current practice of this busy fracture clinic was performed.
Patients and Methods: A Prospective study of three consecutive fracture clinics under the care of a single consultant Trauma and Orthopaedic surgeon was conducted. Total number of patients who attended the fracture clinic, their source of referral, diagnosis and outcomes were documented.
Results: Total number of patients who attended the fracture clinic over three week period was 229. Total number of new patients was 102 and follow-ups were 127. 171 patients were referred from A&E and 43 from minor injury unit. 62 patients had lower limb injuries and 161 pts had upper limb injuries. 180 patients had fractures, 11 had dislocations and 25 had soft tissue injury. The outcome of fracture clinic was that 86 pts were discharged and 109 were given ongoing follow up appointment. Misdiagnosis was made in 19 patients. Time for each consultation was 8 minutes. The commonest error was hand injuries diagnosis.
Conclusion: Increasing burden of trauma care has been identified. Fracture clinic audit can help to reduce errors being made.

J.Orthopaedics 2008;5(3)e11

Introduction:

The provision of trauma care has changed significantly over the last decade in the UK. Most of this care is now consultant led involving daily consultant-led trauma lists and consultant-led fracture clinics which has improved patient care. (6) The burden of trauma care on the National Health Service is increasing day by day because of road traffic accidents, recreational and sporting injuries, alcohol and osteoporosis.   

Musculoskeletal injury is a common cause of emergency department visits, and accounts for about 50% of patients attending Accident and Emergency department. (4) After emergency treatment, these patients are referred to the fracture clinic for follow up of their orthopaedic injuries.  

Edinburgh Orthopaedic Trauma Unit is a tertiary referral centre for south-east of Scotland. It provides the trauma care to all the patients who attend its emergency department along with the emergency department at St Johnís Hospital, Livingston and Minor Injury Unit (Nurse Practitioner led) at Western General Hospital. An Audit to determine the current practice of fracture clinic at the Royal Infirmary of Edinburgh was performed.  

The primary aim was to describe the epidemiological characteristics of patients attending fracture clinics, including age, gender, injury and source of referral.  Secondary aim was to investigate the accuracy of initial diagnosis.

Material and Methods :

A Prospective study of three consecutive fracture clinics under the care of a single consultant Trauma and Orthopaedic surgeon was conducted from the week commencing 3rd December 2007. Total number of patients who attended the fracture clinic, including new patients and follow-ups, their source of referral, diagnosis and outcomes were documented after reviewing the A&E records and fracture clinic notes. Children under the age of 12 years attended the local paediatric hospital, and were excluded from the study. Data was analysed using Microsoft Excel & SPSS.

Results :

Total number of patients who attended the fracture clinic over three week period was 229. Total number of male patients was 125, and total number of female patients was 104. Patients less than 50 Y of age were 145 and patients more than 50 years of age were 84. The total attendances for the 1st 2nd and 3rd week clinic were 82, 76 and 71 respectively. Total number of new patients was 102, (male 57, female 45), and total number of follow-ups was 127 (male 67, females 60). (Fig 1)

Gender of New Patients: (Fig 1)

 

171 patients were referred from A&E, 166 from the local A&E department, and 5 from other A&E departments in England and Europe.  

41 patients were referred from the minor injury unit (Nurse practitioner led), 6 from GPís, 4 from other consultantís clinics, and 1 from physiotherapy. No records were available for 4 patients. (Fig 2)

Referral Patterns: (Fig 2)

 

In local A&E department, 90 patients were seen by emergency doctors, 48 patients were seen by the nurse practitioners, 6 patients were seen by the staff nurse, 3 patients were seen by other doctors and for 19 patients no record was found.

63 patients had lower limb injuries, and 164 had upper limb injuries. 97 males have upper limb injuries as compared to 67 females. On the other hand 36 females have lower limb injuries and 27 males have upper limb injuries (Table 1).

Location of Injury: (Table 1)

 

Upper Limb Injury

Lower Limb Injury

Total

Male

97

27

124

Females

67

36

103

Total

164

63

227

 

 

 

180 patients had fractures, 11 had dislocations, 25 had soft tissue injury, and 8 were referred for other causes including metal work irritation and non union. (Fig 3)

Injury Type: (Fig 3)

The outcome of fracture clinic was that 86 pts were discharged, 12 of those to physiotherapist and rest to the GP. 11 were referred to other consultantís clinics, 8 were referred for radiological studies, 3 were put on the waiting list for surgery, 7 were admitted and 109 were given ongoing follow up clinic appointment.

 Average time for each consultation was 8 minutes. Misdiagnosis was made in 19 patients. 17 patients were seen in A&E department and 2 in minor injury unit. The patients who attended A&E, 10 were seen by emergency doctors, 4 by nurse practitioners, and for 3 no records were found. 15 patients were under 50 years and 4 were over 50. 11 of these were new patients and 8 were follow- ups in the fracture clinic. Out of the 11 new patients, 3 were discharged, 1 was admitted and 7 were given FU appointments. 14 patients had upper limb injury and 5 had lower limb injury. The commonest error was hand injuries diagnosis in 8 patients.

Discussion: 

Fracture clinics were set up in United Kingdom in 1937 for the treatment of fractures (1). Since then the fracture clinics have been routinely used to deal with the trauma patients, with injuries such as fractures, dislocations, sprains and strains in UK.(2)  

The epidemiology of adult fractures is changing with time. (3)  More young males are attending the fracture clinics because of the accidents and sports injuries, while females are presenting in later life because of the osteoporotic fractures. Upper limb injuries are more common than the lower limb injuries in both males and females, although the incidence of lower limb injuries is higher in females.  

Misdiagnosis of orthopaedic injuries has been identified as a major cause for the claims made against A&E.  It is essential for the patient care and financial costs that these misdiagnosis are reduced by the accurate interpretation of the X-rays by a senior doctor in emergency medicine/ radiologist / orthopaedic surgeon as there are no national standards of interpretative accuracy of X-rays (4) 

The rapid review process by a consultant orthopaedic surgeon of all orthopaedic injuries can reduce the number of patients that need to be seen in the fracture clinic and relieves pressure on medical staff, which can improve the patient care provided in the fracture clinic. (4) 

Emergency Nurse Practitioners (ENP) are increasingly managing minor injuries in Accident and Emergency departments across the United Kingdom with good satisfaction rate from the patients. (5) 

With the introduction of Modernising Medical Career and European Working time directive many junior doctors will review patients in fracture clinics with common trauma. It might be necessary to develop discharge protocols for common trauma cases which may prompt a more standardised approach to discharge. It may also be appropriate for specialist cases to be seen in designated clinics, such as a specialist hand clinic. (6)

Reference :

  1. Unknown Author, Fracture clinics. The Lancet 1937 (6) 1470-71

  2. Donaldson LJ, Thomson RG, Cook A, Raymakers R. Eight yearsí experience of clinical activity in an outpatient fracture clinic Injury 1992; 23(6):363-367

  3. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review Injury. 2006 Aug; 37(8):691-7. Epub 2006 Jun 30

  4. Beiri A, Alani A, Ibrahim T, Taylor GJ. Trauma rapid review process: efficient out-patient fracture management. Ann R Coll Surg Engl. 2006;88(4):408-11

  5. Lindsay GM, Kinn S, Swann IJ. Evaluating Emergency Nurse Practitioner services: a randomized controlled trial. J Adv Nurs. 2002;40(6):721-30

  6. Cosker TD, Ghandour A, Naresh T, Visvakumar K, Johnson SR. Does it matter whom you see? - A fracture clinic audit. Ann R Coll Surg Engl. 2006; 88(6):540-2

This is a peer reviewed paper 

Please cite as : Muhammad Adeel Akhtar: Fracture Clinic- Current Practice and Future Trends

J.Orthopaedics 2008;5(3)e11

URL: http://www.jortho.org/2008/5/3/e11

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