Background 

Recent studies and guidelines have indicated a more conservative approach to the management of certain paediatric fractures that could lead to savings in hospital activity, with no detrimental effects on patient outcomes. These approaches include, where appropriate, minimising follow-up appointments, undertaking out-of-theatre manipulations and reducing the number of x-rays. 

Our analysis aims to assess the changes in fracture management over recent years and identify potential further opportunities for activity savings within paediatric fracture management. To do this, we analysed routinely collected data for all those aged 16 and under, who attended an emergency care department in England between 2019/20 and 2023/24, and who had a closed fracture of the forearm, elbow, clavicle, tibia/fibula or toe recorded. Emergency care records were linked to fracture-related inpatient and outpatient activity in the subsequent 3 months, to determine the proportions of emergency care attendances with an outpatient follow-up appointment or a manipulation in theatre. 

Trends in fracture incidence and management 

In a typical year in England, there are between 100-150k closed fractures of forearm, elbow, clavicle, tibia/fibula or toe recorded in A&E.  There is a 4-fold variation in recorded fractures across England’s 42 Integrated Care Boards. 

Between 2019/20 and 2023/24, the proportion of forearm fractures manipulated in theatre decreased by 53%; over half of forearm fracture manipulations are now performed in the emergency department. There has been a moderate decrease in the proportion of fractures that are followed up in outpatients of around 5-12%, depending on fracture type. In 2022/23, 66% of these fractures received at least one follow-up appointment, but there was marked variation between Trusts in the proportion and mode of follow-up attendance (virtual vs. face-to-face) for different fractures. Fractures of the clavicle and toe can be diagnosed without the need for x-rays, but currently around 87% of clavicle fractures and 76% of toe fractures in children are x-rayed. 

Benchmarking 

If the proportion of follow-up appointments was reduced to the level of the lowest decile of providers, around 1/3rd of these outpatient appointments could be saved, equating to around 30,000 appointments per year in England. Similarly, around 5,000 x-rays for clavicle and toes fractures, and 2,000 manipulations in theatre could be avoided each year. 

Conclusion 

While there are trends towards more conservative management of paediatric fractures over time, there is still scope for a significant reduction in fracture management and particularly the number of follow-up appointments for uncomplicated paediatric fractures. Released clinical time and resources could be utilised for other paediatric, orthopaedic, surgical or urgent care services. 

These approaches could also be used to identify similar opportunities in the adult population.

To read more in the published abstract click here.