The Use of Virtual Clinics in the Management of Fractures

A Narrative Review

Benjamin Hickey, BM, MRCS, MSc, FRCS (Tr & Orth), MD; Mithun Nambiar, MBBS, BMedSc; James Randolph Onggo, MBBS (Hons); Mark Whitty, MBBS, FRACS; Harvinder Bedi, MBBS, MPH, FRACS; Raphael Hau, MBBS, FRACS


Curr Orthop Pract. 2020;31(6):582-585. 

In This Article

Upper Limb Trauma

The VFC for upper limb trauma has been reported for treatment of clavicular, radial head or neck, fifth metacarpal and nondisplaced wrist fractures.

In a study[4] of 138 patients with acute clavicular fractures who were referred to the VFC of Glasgow Royal Infirmary over a 1-year period, 45% (n= 62/138) were discharged without any face-to-face fracture clinic appointment, of which 84% (n=52/62) of patients had nondisplaced fracture patterns. At 1-year follow-up (n=44), 91% (n=40/44) of patients who were discharged virtually were satisfied with their recovery. The mean quick Disabilities of Arm, Shoulder, and Hand (quick DASH) score was 16.1, and the mean EuroQol five dimension visual analog scale (EQ-5D VAS) was 78.1. These scores demonstrate good function and quality of life in those discharged virtually. No patients discharged virtually required surgery during the study period; however, four patients who were not satisfied had issues of mild pain (n=1), pain on heavy lifting (n=1), and a visible bump at the fracture site with no functional restrictions (n=2). Of note, 15% (n=21/132) of injuries were nondisplaced midshaft fractures, and all were discharged virtually. It could have been possible for these patients to be discharged directly from the ED with advice rather than being referred to the VFC.

The same unit reported a series[5] of 202 patients who presented to the ED with suspected or actual isolated radial head (Mason type 1 or 2) or neck fractures over a 1-year period. Patients were provided with an informational leaflet about their injury, advising early mobilization, and a fracture clinic helpline contact number to use if they had concerns. ED physicians referred patients directly to the VFC if there were concerns. A consultant radiologist also reviewed all radiographs within 24 hr to ensure no significant fractures were inadvertently discharged directly. Of the patients in this series, 68% (n=138/202) were directly discharged from the ED. After VFC review, 22% (n=45/202) were discharged. Only 10% of patients (n=20/202) required early face-to-face review. Seventy-seven percent of patients (n=155/202) completed a patient satisfaction questionnaire, and 97% (n=150/155) recalled receipt of the informational leaflet, and 95% (n=142/155) reported overall satisfaction with the information provided about their injury. The management of ongoing restriction of forearm rotation with conservatively treated Mason type 1 or 2 radial head fracture was to offer delayed radial head excision or replacement. Only 1% of patients (n=2/202) required late surgical intervention. No validated patient-reported outcome measures were used to assess patient function. This study did not assess cost savings with the new protocol.

The Glasgow Royal Infirmary reported[2] the effect of direct discharge from the ED for patients with isolated fifth metacarpal, pediatric greenstick, clavicular, torus wrist, isolated radial head, radial styloid, and fifth metatarsal fractures. Patients were provided with advice regarding their injury and prognosis, with no follow-up (telephone line advice only). Using this protocol, (23%) (n=2115/6385) patients were directly discharged over a 1-year period. This did not result in any statistically significant increase in the rate of unplanned return visits (2.5% before implementation of program, 1.9% after implementation). In a fracture clinic setting with weekday only clinics, this would equate to approximately eight fewer new patients being seen per day (based on a 260-weekday year).[2] A concern by staff was that direct discharge of patients with orthopaedic conditions from the ED might potentially increase time required by ED staff to explain the diagnosis and provide information regarding recovery. However, a protocol that assessed time from initial review to discharge from the ED for patients with fifth metacarpal fractures, radial head fractures, and metatarsal fractures found no difference in time of review before and after the protocol was implemented. Interestingly, for ankle and radial styloid fractures there was a statistically significant reduction in time (mean 6 min and 13 min respectively). Vardy et al.[2] postulated that the reduction in time may have been the result of applying removable splints for these injuries rather than backslabs after introduction of the protocol.

A study from the plastic and reconstructive surgical unit at Dundee in Scotland, reported the effect of implementing a virtual hand clinic. In a series of 100 patients who were referred to the hand service with acute closed soft-tissue and bony injuries of the hand (excluding carpal and wrist fractures), review of the referrals revealed that only 59 required a "face-to-face" review by a consultant plastic surgeon, of which 44% (n=26/59) required surgery. The remaining 41 patients were either seen directly in the hand therapy clinic (n=38) or referred to another specialty (n=3). None of these patients experienced an adverse event.[6]

Therefore, VFCs were found to be a safe and effective means of improving efficiency in the ED and outpatient clinic for upper limb fractures.