ASSESSING REFERRAL APPROPRIATENESS FOR TORUS (BUCKLE) AND MINIMALLY DISPLACED CLAVICLE FRACTURES TO A PAEDIATRIC VIRTUAL FRACTURE CLINIC

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Abstract

Background Local guidance advises first-contact discharge with safety-netting for torus (buckle) fractures and minimally displaced clavicle fractures (MDCF). This aligns with NICE NG38 and the UK multicentre FORCE randomised trial showing that soft bandage/no routine follow-up is safe and effective for torus fractures (1,2). Despite this, our Virtual Fracture Clinic (VFC) has flagged frequent referrals of these injuries, potentially creating avoidable activity. Methods: Retrospective audit of all paediatric VFC referrals at a large UK teaching hospital during June–September 2023 and June–September 2024. Electronic records (PPM+) were screened to identify children with torus fracture or MDCF who were discharged at VFC without additional intervention. Cases needing further management were excluded. Primary outcomes: (i) proportion of all VFC referrals that were buckle/clavicle fractures (BFC); (ii) among BFC, the proportion originating from the hospital’s paediatric emergency department (ED). Secondary outcome: overall share of ED-originating BFC as a percentage of all VFC referrals. Results: 2023 (n=1,050 referrals): 9.52% were BCF; 5.05% of all VFC referrals were ED-originating BCF (53 contacts). 2024 (n=1,174): 8.52% were BFC; 4.94% were ED-originating BFC (58 contacts). Year-to-year share was similar (-0.11 percentage points). Findings indicate persistent referrals to VFC for injuries intended for first-contact discharge. Conclusions: There is a clear gap between protocol and practice, generating avoidable VFC activity. We are implementing a multi-component quality-improvement package: revised parent/carer materials and safety-netting, refined age/red-flag criteria, and targeted ED teaching. Service goal: reduce ED-originating BFC→VFC referrals by ≥50% within 6 months of implementation while monitoring unplanned reattendance. This pathway optimisation is low-cost, scalable, and likely generalisable to similar VFC models internationally. Governance: retrospective service evaluation using anonymised data; no formal ethics required under local policy.