Management and referral of paediatric fractures by ED staff: Room for improvement.

Abstract

Background: Limb fractures in children are a common presenting problem to emergency departments (EDs).1 Many of these are referred to fracture clinic, some unnecessarily.2-4 State-wide paediatric fracture guidelines were introduced to Victoria in October 2012, with the aim of optimising management of these conditions. Objective(s): To describe the management and referral of paediatric limb fractures presenting to our health service, and to assess outcome of fracture clinic referral. Method(s): Structured retrospective chart review of all patients aged between 0 and 18 years presenting to the 3 EDs of a single Victorian health service during a two month period. Patients were included if they had an ED discharge diagnosis of limb fracture. Data collection included x-ray findings, ED management, consultation and admission by the orthopaedic unit, referral to fracture clinic, and outcome of initial fracture clinic referral. Result(s): 489 presentations were due to limb injuries coded as fracture by emergency department staff. Of these, x-rays were available for 458 patients. 67 (14.6%) of patients did not have a fracture on formal radiology report, while the remaining 391 had a confirmed fracture. Most patients were managed by ED staff without orthopaedic consultation (Table 1), while less than a third of patients required orthopaedic consultation or admission. 31 upper limb fractures were manipulated in the ED. Of these, 4 were subsequently admitted to hospital for further treatment, while another 7 required re-manipulation after review in fracture clinic. 85 children were admitted to hospital for orthopaedic management. Of these 65 (76%) were for upper limb fractures. 288 children were referred to fracture clinic. 21 did not attend for follow-up. Of those 267 seen in fracture clinic, 22 did not have a fracture, and another 30 were discharged from the clinic on the first visit. Another 183 were booked for another review (37% of these had a change to their plaster), while the remaining 32 were booked for surgery. Conclusion(s): Around 25% of paediatric fracture clinic referrals do not result in any significant change in management. This has significant resource implications, and further work is required to improve referral patterns. (Table Presented).