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

Lower Limb Trauma

Studies on VFCs for lower limb trauma have largely focused on management of stable ankle and fifth metatarsal fractures.

In the United Kingdom (UK), prior to introduction of British Orthopaedic Society Standards for Trauma (BOAST) management of ankle fractures, it was not uncommon for patients with conservatively managed Weber B ankle fractures to have multiple ankle radiographs and clinic appointments (average of six radiographs and four clinic appointments).[7] In a series[7] of 53 nonoperatively managed ankle fractures over an 18-month period in the UK, it was reported that no fractures changed position on subsequent radiographs. It should be noted that there was no standardized management protocol for these fractures. Half of these patients were made nonweight-bearing at their initial fracture clinic appointment, and it is unclear how many of the postoperative radiographs were weight-bearing. In a series[8] of 309 patients with suspected stable Weber B ankle fracture at a major trauma center in the UK (defined as no talar shift, syndesmotic widening, medial malleolar fracture, or dislocation), 2% (n=5/309) were considered to have an unstable fracture on initial radiographs when reviewed in the VFC. A further 2% (n=6/309) were considered to be unstable at 2-weeks weight-bearing radiograph and underwent fixation. In contrast to the study by Martin et al.,[7] this suggested that a weight-bearing follow-up radiograph was necessary.[8]

In the study by Bellringer et al.,[8] patients had initial ankle radiographs in the ED and were provided with weight-bearing boots and crutches. They were then referred for review in the VFC and had a weight-bearing radiograph at 2 wk, prior to a 2-week review in a clinic with an extended scope physiotherapist. Then they had additional radiographs and review with the extended scope physiotherapist at 6 wk, at which time most patients were discharged. If there were concerns about clinical or radiographic union, they were referred for review to a specialist clinic. Based on this model, it was calculated that each patient managed with the VFC protocol would cost £509 (approximately AUD$900). Only 0.6% (n=2/314) went on to develop a nonunion and underwent operative treatment, and both were identified later than 1 yr after injury.[8] It was believed that this initial VFC protocol did not reflect modern management of stable Weber B fractures and was therefore not cost effective. The initial radiograph in the ED, provision of a weight-bearing boot, with a face-to-face review in fracture clinic, followed by another clinic review with weight-bearing radiograph 2 wk after injury amounted to a total cost of £382 (approximately AUD$680).[9]

In a subsequent article, Bellringer et al.[10] used an updated version of the VFC model that no longer included a 6-week radiograph or follow-up with a physiotherapist, and amounted to savings of £354 (approximately AUD$630) per patient, which includes the initial radiograph in the ED, provision of a weight-bearing boot with a VFC review, followed by extended scope physiotherapist review with weight-bearing radiograph 2 wk after injury.[10] Therefore, management of stable Weber B fractures using a VFC model could still offer some cost saving when compared with modern management of these injuries through fracture clinics. It was clear that management of stable Weber B fractures with initial radiograph, backslab application followed by check radiograph and crutches (total cost=£80, approximately AUD$140) is not cost effective when compared to performing a single diagnostic radiograph and providing the patient with a weight-bearing boot and crutches (total cost=£48, approximately AUD$85).[8]

It is also important to consider the numbers of patients managed through a VFC to determine the potential cost savings. For example, if the 53 conservatively managed patients in the study by Martin et al.[7] had been managed using a modern VFC model, the annual saving would be £1155 (approximately AUD$2060) when compared to modern management through the fracture clinic described earlier.

Furthermore, it was not cost effective to bring patients back for multiple follow-up appointments, each costing £82 (approximately AUD$145), unless there was a specific reason. A standardized protocol for managing these injuries was therefore at least as important as the VFC itself. Based on the costs used in this paper by Bellringer et al.,[8] a Weber A fracture diagnosed with initial ED radiograph, provided with weight-bearing boot and crutches and VFC review (with no further follow-up) would cost £200 (approximately AUD$350). It could be argued that these fractures did not even require review in a VFC.

Although there is potential for significant cost savings in implementing the VFC model, the perceived cost benefits need to be considered in relation to the set-up costs of implementing a VFC. Furthermore, the above studies related to the UK health care setting and may not be directly comparable to Australia.

In a study[1] of 663 patients with fifth metatarsal fractures (or suspected fractures) over a 2-year period, a standardized management protocol included initial ED radiograph and provision of a weight-bearing boot (with crutches if required). All radiographs were reviewed the next day in the VFC by an extended scope practitioner (under consultant supervision). Patients were then sent a letter detailing their diagnosis, management plan, and prognosis. They were provided with a VFC telephone contact number to call if concerned at any time. All patients were discharged at this point except for Jones' fractures (type 2 fractures), which could either have "face-to-face" follow-up or be discharged (decided by clinician).

In that study,[1] 38% (n=251/663) were avulsion fractures, 17% (n=112/663) were Jones fractures, 40% (n=267/663) were type 3 or midshaft fracture, 1% (n=9/663) were a distal head/neck fracture, and 4% (n=24/663) either had no fracture or no available radiograph.[1] For the majority of cases this VFC model the cost for the initial visit to the ED was £87, the initial radiograph was £27, the weight-bearing boot was £13, the crutches were £4, and review in the VFC clinic was £64 for a total of £195 (approximately AUD$350). In comparison, the traditional model of suspected fifth metatarsal fracture management (excluding Jones fracture), would be the same cost as a standard VFC (£195), but in addition, the patient would have been provided with backslab in the ED (£18), and seen in the subspecialty fracture clinic (£138) rather than the VFC (£64). This would bring the total cost to £287 (approximately AUD$510), which is £92 (approximately AUD$160) more expensive per patient.

If the patient had a suspected Jones fracture in the VFC, they would have an additional radiograph and a follow-up clinic appointment, which would cost £304 (approximately AUD$540) in total. A Jones fracture managed by the traditional pathway would be as above but would also have an additional follow-up clinic visit for £82, a cast with shoe for £43, and more radiographs, which would cost an average of £81. Therefore the total cost of traditional clinic management of Jones fracture would be £430 (approximately AUD$770), which is £126 (approximately AUD$230) more expensive per patient.[1] Through VFCs, for the management of fifth metatarsal fractures, there was a saving of £62,600 (approximately AUD$112,000) for the hospital network over 2 yr.[1]

All patients with a fifth metatarsal fracture were referred to the VFC in the first instance so that a Jones fracture would not be missed. Considering the 251 patients with type 1 avulsion fracture of the fifth metatarsal treated through a VFC, only 2% (n=5/251) sustained a non union. None of these patients were symptomatic. Of patients with Type 2 (Jones) fracture, 7% (n=8/112) developed a nonunion, and at least half had minimal symptoms and did not want to consider surgery. None of the patients with type 3 fractures (n=267) developed a nonunion.[1] If there was a safe mechanism for review of the initial radiograph, only Jones fractures would be referred to the VFC, resulting in a greater cost saving.[1]

In a further study from Glasgow Royal Infirmary it was shown that definitive management of fifth metatarsal fractures could be made in the ED.[11] Patients were given elastic bandages or weight-bearing boots and discharged with advice from the ED without follow-up. They were provided with a telephone contact number if they had ongoing problems. Staff in the ED only referred selected patients to a VFC if they were in doubt of the injury.[11] Before implementing the direct discharge protocol, 97% (n=270/279) of patients attended the foot and ankle trauma clinic. 32.6% of patients (n=91/279) were treated with casts. Most of the patients were treated with an elastic or crepe bandages (59%). After implementing the protocol, 20% (n=66/339) of patients required review in the foot and ankle trauma clinic.[11]

After direct discharge from the ED was instituted, 47% of patients (n=159/339) were provided with elastic or crepe bandages, the percentage of patients provided with casts significantly decreased (1.8%, n=6/339), and the percentage of patients provided with weight-bearing boots significantly increased (from 2.9% before to 27.2% after).[11] Importantly, implementation of the direct discharge pathway, with VFC if required, did not increase the number of patients who sustained nonunion (0.6% vs 0.4%) or required surgical treatment (1.1% vs 1.2%).[11] A total of 78% (n=169/216) of patients were satisfied with their injury outcome. However, it should be noted that 18% (n=39/216) were either unsatisfied or very unsatisfied with their injury outcome. The reasons for unsatisfactory outcomes were not explicitly reported by Ferguson et al.[11] and would require further investigation.

There was evidence that VFCs were both safe and cost effective for the treatment of lower limb trauma, particularly stable ankle fractures and fifth metatarsal fractures.