Excerpt

Two of the five guidelines in the NICE trauma suite relate to fractures. These are titled non-complex and complex fractures. In broad terms, non-complex fractures are those likely to be treated at the receiving hospital, whereas complex fractures require transfer or the consideration of transfer of the injured person to a specialist.

The annual incidence of fractures in Britain is estimated at 3.6% and the lifetime prevalence of fracture is near 40%.⁴⁷ The majority of the 1.8 million fractures occurring every year in England are non-complex. These include a very wide range of injuries. The injured person may be any age from infancy to elderly. There are many anatomical sites at which a fracture may occur. The mechanisms of injury are many and varied. The range of treatment options is wide and varied. Because of these factors, non-complex fractures present an enormous challenge to healthcare systems.

Many non-complex fractures have a benign natural history and minimal clinical intervention is required. The nature of healthcare systems can be to overcomplicate matters; individuals offering treatment within their own field of expertise. Thus, surgeons may tend to operate and physiotherapists to provide therapy. A pathway expending unnecessary time and effort can evolve. Some non-complex fractures can present as an apparently minor and easily missed injury, yet still have a potential for a poor long-term outcome; scaphoid fracture is an example. Therefore, there is a need to explore a framework where important injuries are not missed whilst avoiding over-treating the majority of patients who have a benign injury.

It is clear that a single guideline cannot address individually all potential situations. However, since non-complex fractures present a huge burden and workload to the NHS it is a sound objective to provide a guideline to act as a rational basis for patient management embracing and accepting a wide range of circumstances. To this end, the guideline is based around a group of indicative topics chosen in the scoping stage of development.

Instead of tracing the pathway of a single injury, the guideline topics were chosen to inform various stages on a notional pathway of patient care. These topics were chosen on the basis of their prevalence, their relevance to a particular step in the patient pathway of care or perceived variation in current practice. It was inherent in the development of the guideline that, whilst recommendations are necessarily only made in relation to the individual topics of the scope, these recommendations should be considered as representative of the management of non-complex fractures in general.

Contents

• National Clinical Guideline Centre
• Acknowledgements
• 1. Foreword
• 2. Introduction
• 3. Development of the guideline
  • 3.1. What is a NICE clinical guideline?
  • 3.2. Remit
  • 3.3. Who developed the trauma guidelines?
• 4. Methods
  • 4.1. Developing the review questions and outcomes
  • 4.2. Searching for evidence
  • 4.3. Evidence gathering and analysis
  • 4.4. Evidence of cost-effectiveness
  • 4.5. Developing recommendations
• 5. Guideline summary
  • 5.1.1. Full list of recommendations
  • 5.1.2. Additional recommendations
  • 5.2. Key research recommendations
• 6. Initial pain management
  • 6.1. Initial pharmacological pain management
  • 6.2. Paediatric nerve blocks femoral fractures
• 7. Acute stage assessment and diagnostic imaging
  • 7.1. Selecting patient for imaging – clinical prediction rules for knee fractures
  • 7.2. Selecting patients for imaging – prediction rules for ankle fractures
  • 7.3. Imaging of scaphoid
  • 7.4. Hot reporting
• 8. Management and treatment plan in the emergency department
  • 8.1. Timing of reduction and imaging guidance – distal radius fractures
  • 8.2. Reduction anaesthesia – distal radius fractures
  • 8.3. Treatment of torus fractures
  • 8.4. Referral for on-going management from the emergency department
• 9. Ongoing orthopaedic management
  • 9.1. Non-surgical orthopaedic management of unimalleolar ankle fractures
  • 9.2. Ankle imaging
  • 9.3. Timing of surgery – ankle fractures
  • 9.4. Timing of surgery – distal radius fractures
  • 9.5. Definitive treatment – distal radius fractures
  • 9.6. Definitive treatment – proximal humerus fractures
  • 9.7. Definitive treatment – femoral fractures in children
  • 9.8. Post-operative mobilisation – distal femoral fractures
  • 9.9. Post-operative mobilisation – ankle fractures
• 10. Documentation, information and support
  • 10.1. Documentation
  • 10.2. Information and support
• 11. Access to the skills required for the management of people with fractures
  • 11.1. Introduction
• 12. Acronyms and abbreviations
• 13. Glossary
• References
• Appendices A-F
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Review protocols
  • Appendix D. Clinical article selection
  • Appendix E. Economic article selection
  • Appendix F. Literature search strategies
  • References
• Appendices G-I
  • Appendix G. Clinical evidence tables
  • Appendix H. Economic evidence tables
  • Appendix I. GRADE Tables
  • References
• Appendices J-Q
  • Appendix J. Forest plots
  • Appendix K. Excluded clinical studies
  • Appendix L. Excluded economic studies
  • Appendix M. Cost-effectiveness analysis: Imaging of suspected scaphoid fractures
  • Appendix N. Mapping of DRAFFT trial data to predict an EQ5D index score from a PRWE score
  • Appendix O. Qualitative study checklist
  • Appendix P. Research recommendations
  • Appendix Q. NICE technical team
  • References

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and, where appropriate, their guardian or carer.