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EDITORIAL |
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Fracture Clinic- Current Practice and Future Trends |
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Muhammad Adeel Akhtar, Christopher W Oliver
*Royal
Infirmary of Edinburgh, United Kingdom.
Address for Correspondence:
E
Mail: m_adeel_akhtar@yahoo.com
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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 John’s
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 GP’s, 4 from other consultant’s
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)
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Upper Limb Injury |
Lower Limb Injury |
Total |
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Male |
97 |
27 |
124 |
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Females |
67 |
36 |
103 |
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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 consultant’s 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 :
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Unknown Author, Fracture clinics. The Lancet 1937 (6) 1470-71
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Donaldson LJ, Thomson RG, Cook A, Raymakers R. Eight years’
experience of clinical activity in an outpatient fracture clinic
Injury 1992; 23(6):363-367
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Court-Brown CM, Caesar B. Epidemiology of adult fractures: A
review Injury. 2006 Aug; 37(8):691-7. Epub 2006 Jun 30
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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
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Lindsay GM, Kinn S, Swann IJ. Evaluating Emergency Nurse
Practitioner services: a randomized controlled trial. J Adv Nurs.
2002;40(6):721-30
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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
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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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