Paediatric fracture clinic design--current practice and implications for change

In our region there has been considerable success in the redesign of adult fracture clinics. The aim of this study was to define our paediatric fracture clinic load, to assess the feasibility of increasing efficiency by decreasing inappropriate attendance.

Prospective case notes review of all attendees at 6 serial fracture clinics at the Royal Hospital for Sick Children (Glasgow) which has both local and tertiary referrals. Of 234 consecutive attendances across 6 fracture clinics, 34 (15%) were judged inappropriate: 13 had fractures not requiring orthopaedic follow-up (radial torus/clavicle/undisplaced metacarpal), and 21 had diagnoses or situations that were not appropriate. Of the 200 attendances deemed appropriate (172 fractures, 11 soft-tissue injuries, 9 infections and 8 acute atraumatic limps), there were 33 new referrals from the emergency department, and a further 39 were first-time attenders at the fracture clinic after an acute admission (37 were post-operative and 2 were non-operative). Of these 200, the treatment plan was changed for 67 (34%), a cast removed or exchanged for 92 (46%), and radiographs taken for 153 (77%). The overall discharge to return ratio was 76:158 (1:2.1), and for appropriate attenders 61:139 (1:2.3).

Tighter discipline can be applied to indications for fracture clinic appointments, including certain fracture types being discharged from the emergency department without unnecessary review - our particular fracture clinic numbers can be decreased by 15%. In the remaining attendances there are high radiograph and intervention rates, such that it seems unlikely that further reductions in attendance would be feasible.