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Optimising Management of Paediatric Distal Radius Torus Fractures: A Complete Two-Cycle Audit Assessing Compliance
Praveen Rajan1, Srinath Pammi1, Venkata Nutalapati2
1Trauma and Orthopaedics, Basildon University Hospital, Basildon, GBR.
Insights
Quality improvement interventions significantly boosted adherence to NICE NG38 guidelines for paediatric distal radius torus fractures. While unnecessary follow-ups decreased, immobilisation practices remain inconsistent, especially in minor injury units.
Area of Science:
- Paediatric Orthopaedics
- Quality Improvement in Healthcare
- Clinical Audit
Background:
- Distal radius torus fractures are common paediatric injuries.
- National Institute for Health and Care Excellence (NICE) guideline NG38 recommends non-rigid immobilisation and no routine follow-up.
- Clinical practice for these fractures varies significantly across healthcare settings.
Purpose of the Study:
- To assess baseline compliance with NICE NG38 for paediatric distal radius torus fractures.
- To implement targeted quality improvement interventions.
- To evaluate the impact of these interventions through a closed-loop audit.
Main Methods:
- A two-cycle retrospective clinical audit was performed at a District General Hospital (DGH) and Minor Injury Unit (MIU).
- Cycle 1 established baseline practice (n=222), followed by interventions (clinician education, guideline dissemination, visual prompts).
- Cycle 2 evaluated post-intervention practice (n=258), collecting data from electronic records and radiographic systems.
Main Results:
- Baseline NICE NG38 compliance was 56% at DGH and 0% at MIU, with 58% of patients having unnecessary follow-up.
- Post-intervention, compliance improved to 80% at DGH and 31% at MIU.
- Overall fracture clinic follow-up reduced from 58% to 38%; however, rigid immobilisation persisted in 20% of DGH and 69% of MIU patients.
Conclusions:
- Targeted educational and environmental interventions improve adherence to evidence-based guidelines and reduce unnecessary referrals.
- Variability in immobilisation practice, particularly at MIUs, highlights the need for sustained system-level interventions.
- Standardised clinical pathways and ongoing audits are crucial for consistent management of paediatric distal radius torus fractures.
Background:
Distal radius torus (buckle) fractures are among the most common paediatric injuries presenting to emergency departments. National Institute for Health and Care Excellence (NICE) guideline NG38 recommends management with non-rigid immobilisation and discharge without routine follow-up. Despite robust evidence supporting this approach, clinical practice varies considerably across NHS settings.
Aim:
This study aims to assess baseline compliance with NICE NG38 in the management of paediatric distal radius torus fractures, implement targeted quality-improvement interventions, and evaluate their effect through a complete closed-loop audit cycle.
Methods:
A retrospective two-cycle clinical audit was conducted at a District General Hospital (DGH) and its associated Minor Injury Unit (MIU) within the same NHS trust in the United Kingdom. Cycle 1 (February 2023 to August 2023, n = 222) established baseline practice. Interventions included clinician education, guideline dissemination, and visual prompts. Cycle 2 (March 2024 to September 2024, n = 258) evaluated post-intervention practice. Data were collected from electronic emergency department records, radiographic systems, and Virtual Fracture Clinic (VFC) documentation.
Results:
In Cycle 1, compliance with NICE NG38 was 97/174 (56%) at the DGH and 0/48 (0%) at the MIU; 128/222 (58%) of all patients across both sites received unnecessary fracture clinic follow-up. Following interventions, Cycle 2 demonstrated improved compliance to 131/164 (80%) at the DGH and 29/94 (31%) at the MIU. Overall fracture clinic follow-up was reduced from 128/222 (58%) to 98/258 (38%). Rigid immobilisation persisted in 33/164 (20%) of DGH patients and 65/94 (69%) of MIU patients in Cycle 2.
Conclusion:
This closed-loop audit demonstrates that targeted educational and environmental interventions can meaningfully improve adherence to evidence-based guidelines and reduce unnecessary fracture clinic referrals. However, variability in immobilisation practice persists, particularly at the MIU, underscoring the need for sustained system-level interventions, standardised clinical pathways, and ongoing audit cycles.
