British Orthopaedic Association Research Articles

Diagnosis and management of arterial injuries associated with limb fracture or dislocation.

An arterial injury is a time-critical emergency and, when associated with a fracture or dislocation, its management requires joint specialist input from orthopaedic and vascular or plastic surgeons. Initial management involves haemorrhage control and stabilisation of the patient, reduction and splinting of the limb and careful reassessment. With ongoing vascular compromise, urgent surgery is indicated to restore arterial flow and stabilise the skeleton, and this should be performed at a centre with appropriate expertise. This article provides an evidence-based review of the British Orthopaedic Association Standards for Trauma for the diagnosis and management of arterial injuries associated with extremity fractures and dislocations.

Management of open elbow fractures: experiences and outcomes from a UK major trauma center.

Open fractures about the elbow are an infrequent but complex injury with limited existing literature. The aims of the study were to review the treatment strategies of open elbows fractures, functional outcome and complication rates associated with the injury, and correlate the outcome with the topography of the fracture. Patients (n = 21) with open elbow fractures injuries over a 2-year period were analyzed. They were assessed regarding the orthoplastic characteristics of their injury as well any other associated injuries. Outcomes were assessed objectively (achievement of bony union, range of movement, infection status, need for further procedures) and subjectively (Oxford Elbow Score, EQ-5D, EQ-VAS). The commonest grade of open injury was grade 3 (43%). Associated orthopedic injuries were present in 62% and associated system injuries in 57%. Almost half of the patients were noted to have had a significantly increased presenting mortality risk as per Injury Severity Score assessment. Mean time to first wound débridement was 31 hours. There were no cases of deep or chronic infection. Complete bony union was noted in 85% of patients, and 48% of patients required removal of metalwork. Subgroup analysis of the cohort by fracture topography (single unipolar elbow bone injury vs. multiple elbow bony injuries) demonstrated no significant difference (P > .05) regarding rate of complication or final Oxford Elbow Score, EQ-5D or EQ-VAS. Patients with injuries that involved the distal humerus had the highest rate for further procedures (P < .05). The average Oxford Elbow Score, EQ-5D, and EQ-VAS scores for the whole cohort at final follow-up were 37.4, 0.54, and 62.18, respectively. Open elbow injuries are usually from high-energy trauma and often combined with other significant injuries. As a result, the timelines to elbow surgery were often delayed. However, this did not impact the local infection rates nor did it necessitate further surgery, but made achieving all British Orthopaedic Association Standards for Trauma targets difficult. Chronic infection was not an issue in this cohort. Subgroup analysis indicates open distal humerus fractures carry the highest risk for further procedures. This is most commonly in the form of removal of metalwork and fibrinolysis. End outcomes for patients with open elbow fractures can be positive, despite the notable presenting Injury Severity Score. A subspecialist elbow and orthoplastic approach whenever possible is advocated.

Complication rates in operatively managed ankle fracture/dislocations: The effect of pre-reduction imaging and compliance with British Orthopaedic Association Standards for Trauma 12 guidance

Introduction The British Orthopaedic Association Standards for Trauma (BOAST 12) guidelines for the management of ankle fractures aims to optimize recovery and reduce complications. Within the emergency department (ED), they advised urgent reduction of clinically deformed ankles, with radiographs prior only if this would not cause an unacceptable delay. The primary aim of this study was to assess the effect of time to acceptable reduction on the risk of complications and time to definitive reduction. Methods This was a retrospective observational study of patients presenting with ankle fracture dislocations between 2013 and 2017. Patients were divided into two groups with and without radiographs prior to reduction of their injury. Results A total of 242 patients were identified. The time taken from arrival to achieving an acceptable reduction was significantly longer in patients who received pre-reduction radiographs versus patients who did not (184.5 min vs 82, p &lt; .00). The key finding of this follow-up study was that the overall risk of complications and soft tissue complications was not associated with an increased time to reduction ( p = .62). Time to definitive operative management was similar between the two sub-groups (immediate reduction 1 day vs 2, p = .72). Conclusion This study has shown that the use of pre-reduction radiographs in the management of ankle fracture dislocations significantly increases the time to reduction. However, this is not associated with an increased risk of complications or a longer time to definitive management. Further research is needed into the prognostic effect of prolonged ankle dislocation on soft tissues and long-term functional outcome.

Types, management and complications in paediatric distal radial fractures sustained during COVID-19 lockdown.

In response to the coronavirus pandemic the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines advised treating distal radial fractures non-operatively where possible. A cohort was studied retrospectively to assess whether the COVID pandemic lockdown within the UK altered types, the management and complications of paediatric distal radial fractures. The cohort studied comprised of 194 paediatric distal radial fractures in the pre-COVID cohort and 101 fractures in the COVID cohort. There was no significant differences in the type of fractures in the two cohorts. Significantly more high energy injuries were sustained among the COVID cohort than the pre-COVID (p < 0.001). The COVID cohort had significantly more patients managed in cast (p < 0.001) and significantly more managed with K-wire fixation (p = 0.049). The COVID cohort had significantly more complications (p = 0.016) at minimum 10-month follow-up. The results suggest that treatment of paediatric distal radial fractures during lockdown was too conservative and subsequent complications may put additional strain on orthopaedic services.Level of evidence: IV.

Review of K.H. Pridie (1959) on “A method of resurfacing osteoarthritic knee joints”

This classic discusses the original publication “A method of resurfacing osteoarthritic knee joints” by Dr K.H. Pridie (1959), where this pioneer surgeon described a newly developed method for the treatment of osteoarthritic joint surfaces of the knee, which he named subchondral drilling. This short and concise 11-line publication appeared in the Proceedings of the Congress of the British Orthopaedic Association. It has generated 464 citations since 1959, becoming part of the hundred most-cited publications in knee research. Pridie introduced in clinical experimentation the entity of Marrow Stimulation Techniques to liberate mesenchymal stem cells from cancellous bone. He was aware that the results induced, in terms of quality of the regrown tissue, was limited and “only” fibrocartilage. His idea might have been raised from the work of numerous animal researchers who confirmed repeatedly since 1905 that cartilage needed an osseous perforation to heal. Although the past 60 years brought modifications from the technique described in the original article, the concept of marrow stimulation introduced by Pridie remains the most frequently used in cartilage repair surgery today.

Supracondylar fractures of the humerus in children: is departmental documentation hitting national standards?

The British Orthopaedic Association's Standards for Trauma for the management of supracondylar humerus fractures in children specify that: 'A documented assessment of the limb, performed on presentation, must include the status of radial pulse, digital capillary refill time and the individual function of the radial, median (including anterior interosseous) and ulnar nerves.' The documentation of cases of supracondylar humerus fractures over 1 year was retrospectively analysed. An electronic pro forma for supracondylar humerus fractures was introduced, with prompts for the pieces of documentation required to meet national standards. The use of this pro forma was audited after 6 months and 12 months use. Documentation ranged from 10% for anterior interosseous nerve to 53% for radial pulse. In the second reaudit, documentation ranged from 86% for anterior interosseous nerve to 95% for median nerve function. There were 17 patients for whom all documentation was present, and for these patients the pro forma had been used. Use of an electronic clerking pro forma improves adherence. Full documentation of neurovascular status in paediatric supracondylar fractures is vital to allow for effective preoperative and postoperative further assessment. With the move into paperless documentation, online pro formas can help clinicians with effective assessment and documentation.

Anthropometric method for estimating component sizes in total hip arthroplasty.

BACKGROUNDPreoperative templating is essential in total hip arthroplasty (THA) as it not only helps to facilitate the correct implant type and size but also determines the post-operative biomechanics. Templating is also increasingly important from a medico-legal perspective and recommended in the British Orthopaedic Association Guide to Good Practice. Although templating has become increasingly digitised, there are no simple anthropometric models to predict implant sizes in the absence of digital methods.AIMTo assess the accuracy of using an easily obtainable measurement (shoe size) to predict component sizes in THA compared with digital templating.METHODSDigital radiographs from a cohort of 102 patients (40 male, 62 female) who had undergone uncemented or hybrid THA at a single centre were retrospectively templated to desired cup and stem sizes using TraumaCad®. We compared the templated size to the actual size of the implant and assessed if there was any correlation with the patient’s shoe size.RESULTSStatistically significant positive correlations were observed between: shoe size and templated cup size (ρ = 0.92, P < 0.001); shoe size with implanted cup size (ρ = 0.71, P < 0.001); shoe size and templated stem size (ρ = 0.87, P < 0.001); and shoe size with implanted stem size (ρ = 0.57, P < 0.001). Templated and implanted acetabular cup sizes were positively correlated (ρ = 0.76, P < 0.001) and were exact in 43.1% cases; 80.4% of implanted cup sizes were within 1 size (+/- 2 mm) of the template and 100% within 2 sizes (+/- 4 mm). Positive correlation was also demonstrated between templated and implanted femoral stem sizes (ρ = 0.69, P < 0.001) and were exact in 52.6% cases; 92.6% were within 1 size of the template and 98% within 2 sizes.CONCLUSIONThis study has shown there to be a significant positive correlation between shoe size and templated size. Anthropometric measurements are easily obtainable and can be used to predict uncemented component sizes in the absence of digital methods.

The Impact of COVID-19 Restrictions and Changes in Guidelines on Adult Wrist Fracture Management.

Background The coronavirus disease 2019 (COVID-19) pandemic had an unprecedented impact on the healthcare service of the United Kingdom. This study aims to evaluate the effect on wrist fracture care as a result of the COVID-19 pandemic, changes in British Orthopaedic Association Standards of Trauma and Orthopaedics wrist fracture management guidelines, and introduction of lockdown restrictions. Methods This is a retrospective observational study with data collected using the Pathpoint eTrauma platform (Open Medical, United Kingdom). All adults (18 years + ) admitted with wrist fractures within the study phases to Manchester University National Health Service Foundation Trust were included. Each phase of the study period represents a change in lockdown restrictions, including lockdown 1, period of eased restrictions after lockdown 1, lockdown 2, and lockdown 3. These phases were then compared with a prepandemic period. A total of 608 referrals were included for analysis. Results The number of referrals per week decreased from 9.94 prepandemic to as low as 8.12 during lockdown 2. Falls remained the most common mechanism of injury, followed by cycling that saw an increase by more than threefold from 2.42% prepandemic to 8.17% ( p = 0.500) during lockdown 1 and 8.77% ( p = 0.0164) during the easing of lockdown 1. Sports-related injuries and occupational injuries decreased throughout. Assaults and altercations, road traffic accidents, roller-skate, and skateboard-related injuries increased throughout. Surgical procedures per week decreased from 5.06 prepandemic to as low as 4.55 during lockdown 1. Procedure cancellations remained steady apart from an increase during lockdown 2. Referrals managed operatively increased from 50.9% prepandemic to 58.9% in lockdown 2, before dropping to 49.2% in lockdown 3. Mean time from presentation to surgery increased from 9.08 days prepandemic to 16.27 days in lockdown 1 but decreased to just below the prepandemic baseline thereafter. Conclusion Overall, there was a decrease in the number of wrist fracture referrals and surgical procedures compared with before the pandemic. There was also an increased wait-time to surgery and an increased rate of cancellations. Statistical analyses fail to find significance in changes other than mechanisms of injury, which resulted from lockdown restrictions. Therefore, service provision, delivery, and efficiency not affected significantly by changes in guidelines and lockdown restrictions.

Changing to Removable Casts During the Coronavirus Pandemic-Has It Affected Outcomes for Distal Radius Fractures?

BOAST (British Orthopaedic Association Standards for Trauma & Orthopaedics) guidelines recommended that during the coronavirus pandemic most upper limb fractures should be treated conservatively, and removable casts should be used, where possible. As a result, our district general hospital started using a new soft combination (soft-combi) casting technique for conservative management of distal radius fractures (DRFs) in an attempt to reduce follow-up attendances.To assess if radiological outcomes of soft-combi casts are better or worse than previously used rigid casts for DRFs.Twenty DRFs treated with soft-combi casts were compared with 20 DRFs treated with the old rigid cast types. Radiological parameters were measured pre-manipulation, post-manipulation, at 2-week follow-up, and at final follow-up. Statistical analysis was performed to assess for significant differences seen at follow-up between the groups.The mean loss of volar angulation seen at 2-week follow-up was 4.9° for the rigid casts vs. 1.5° for the soft-combi casts (p = 0.158; 95% CI, − 8.17 to 1.38). The mean loss of radial height after 2 weeks was 0.2 mm vs 0.5 mm (p = 0.675; 95% CI, − 1.09 to 1.66), and the mean loss of radial inclination was 2.0° vs 1.0° (p = 0.349; 95% CI, − 2.96 to 1.07), respectively.The soft-combi casts appeared to be equally effective at maintaining the reduction of DRFs compared to their rigid counterparts, as no statistically significant difference was seen in our study. We can be reassured that continued use of these removable casts in the current climate is unlikely to have a detrimental effect on outcomes for DRFs.

Use of abbreviations in consent forms for orthopaedic surgery: A pilot study

BackgroundConsent is a process of communication and the consent form is an important legal document of the evidence of discussion between doctor and patients. We observed frequent use of abbreviations in the consent forms in our department that can result in misunderstanding and miscommunication when consenting patients for orthopaedic procedures. MethodsWe completed an audit cycle starting by reviewing a total of 350 consent forms retrospectively in level one trauma centres in October–November of 2019 for different orthopaedic trauma procedures. The standards for the project were guidelines published by the general medical council (GMC), The royal college of surgeons (RCS) Glasgow, and the British orthopaedic association (BOA).The results were presented at our mortality and morbidity meeting. Written Feedback was obtained from the attending members on how a change can be implemented to increase ccompliance in filling consent forms. A generic email was sent to all medical professionals to avoid the use of abbreviations on the document and encourage colleagues to point out errors if they spot them. The use of full medical terms and to avoid abbreviations in consent form was well advertised, The re-audit was performed for the period of January & February 2020 that included 400 consent forms. The results were analysed and compared with our original audit results. ResultsThe use of abbreviations declined from 54% in first audit to 22% in the re-audit. DVT and PE were the most common abbreviations. ConclusionThis audit cycle has shown the importance of education and reminders to the health professionals in achieving better adherence to the guidelines and improves patient care.

1453 Assessing Procedure-Specific Risk Discussion in Elective Arthroplasty

Abstract Introduction Improper consent is a failure of clinical care and also a major cause of litigation within health care authorities. 4% of surgical negligence claims are attributed to improper consenting in the NHS, with an average settlement fee of approximately £40,000 per claim. Improving quality of consenting therefore not only improves patient care but could also reduce healthcare cost. Method A retrospective analysis of 100 elective hip and knee arthroplasties at a district general hospital in the South of England. Clinic letters and consent forms were reviewed, using the British Orthopaedic Association (BOA) consent proforma as a comparison standard. Quality of consent was reviewed based upon inclusion of BOA associated risks. Results 40% of hip arthroplasty clinic letters and 20% of knee arthroplasty clinic letters did not include a risk discussion. Common risks on consent forms when compared to BOA standards were 84.8% compliant in knees and 88.8% in hips. Less common risks on consent forms were 100% compliant in knees and 96% in hips. Rare risks on consent forms were 74.8% compliant in knees and 57.7% in hips. Notably blood clots and infection were consented for in almost all patients. Risk of death meanwhile, was only consented for 62% of the time, across both procedures. Conclusions Standard of consenting in this audit falls short of BOA standards. Improvement is needed to improve patient care and avoid medical litigation. An integrated electronic form linking consent process of both outpatient and pre-operative review could be a beneficial intervention.

191 Improving Consent and Legibility in Orthopaedic Surgery Through Introducing Pre-Populated Stickers

Abstract Aim Incomplete informed consent can lead to patient dissatisfaction and litigation.1 Time constraints, legibility, human error, limit completion of consent forms, putting surgeons and trusts at risk of litigation.2 The aim of this project was to assess legibility and completeness of handwritten consent forms, with the objective to improve legibility to 100% and risks listed to 100% of those endorsed by the British Orthopaedic Association (BOA).3 Method An initial baseline study in multiple hospitals across the UK identified 113 patients who underwent hemiarthroplasties. The consent forms were assessed for legibility and risks included, compared to those listed by the BOA. Pre-populated risks stickers were introduced in 1 district general hospital (DGH) and 2 cycles repeated again (62 patients identified). Results Overall, 35% of consent forms 1 were illegible; 100% of the time in the risks section. Mean number of risks missing was 2.34 and most frequently missed risk was ‘death’ (missing on 35.5% of consent forms). In the DGH that introduced stickers, consent forms were 100% legible and 100% compliant to the standards set by the BOA when the stickers were used. However, sticker use remained low; only used 20% of the time in the second cycle, marginally increased from the previous cycle (18%). Conclusions A high proportion of consent forms are not completed to BOA standards and are illegible. Pre-populated stickers could aid in achieving 100% legibility and 100% risk inclusion. The stickers will be implemented in other trusts and methods to increase compliance with sticker use will be trialled.

42 An Analysis of Virtual Fracture Clinics in Orthopaedic Trauma in the UK During the Coronavirus Crisis

Abstract Aim Virtual Fracture Clinics (VFC) are advocated by new Orthopaedic (British Orthopaedic Association) and National Health Service (NHS) guidelines in the United Kingdom. We discuss benefits and limitations, reviewing the literature. As well as recommendations on introducing a VFC service during the Coronavirus pandemic and into the future. Method A narrative review identifying current literature on virtual fracture clinic outcomes when compared to traditional model fracture clinics in the UK. We identify 9 relevant publications related to VFC. Results The Glasgow Model initiated in 2011 has become the benchmark. Clinical efficiency can be improved, reducing the number of ED referrals seen in VFC by 15%-28% and face to face consultations by 65%. 33-60% of patients may be discharged after review in the VFC. Some studies have shown no negative impact on the Emergency Department (ED), the time to discharge was not increased. Patients satisfaction ranges from 91%-97% using a VFC service, and there may be cost saving benefits annually from £67,385-£212,705. Non-attendance may be reduced by 75% and there are educational opportunities for trainees. However, evidence is limited, 28% of patients prefer face-to-face consultations and not all have access to internet or email (72%). Conclusions We propose a pathway integrating the VFC model, whilst having Senior Orthopaedic decision makers available in ED, during normal working hours, to cope with the pandemic. Beyond the pandemic, evidence suggests the Glasgow model is viable for day-to-day practice.

108 Neck of Femur Fractures: Streamlined Approach to Improve Consenting Practices

Abstract Aim Neck of femur fractures (NOFs) are synonymous with frailty, and successful outcomes are achieved with operative fixation. The United Kingdom’s General Medical Council guidance governing consent highlights the importance of thorough pre-operative discussion of risk with the patient. We aimed to audit consenting practices in NOF patients within our unit against the British Orthopaedic Association’s (BOA) criteria, with the addition of delirium as a risk factor. Method In cycle one all operatively managed NOFs over a two-month period in October-November 2019 were retrospectively reviewed. Consent forms 1 (CF1) and 4 (CF4) were assessed against BOA-endorsed criteria. Our intervention included a standardised sticker detailing 14 important risks was introduced and a departmental seminar on delirium. A second cycle was undertaken from August-October 2020 to close the audit loop Results No consent form documented all BOA-approved risk factors in cycle one (N = 35). Of cycle two’s 35 patients, 70.8% CF1 were completed using the novel sticker. All of these had 100% BOA-approved risk documentation. Consent forms without the sticker in cycle two documented 9/14 risks (mean value). No CF4 had any risks documented in either cycle. Delirium was documented in 51% in total and in 75% patients with CF1. Delirium documentation improved from 2.9% in cycle one to 51.4% in cycle two. Conclusions Clear lapses in operative consenting processes were identified, especially regarding delirium and CF4 documentation. The introduction of a novel consent sticker drastically improved compliance with BOA guidance for CF1. Recognition and departmental education regarding delirium significantly reduced incidence between cycles.

342 A Closed Loop Audit on The Quality of Documented Consent in Orthopaedic Procedures

Abstract Aim A thorough discussion of associated risks is essential when obtaining informed consent for any surgery. The consent form serves as a permanent record of the conversation and can have implications as a legal document in court. The aim of this audit was to assess the quality of documentation on consent forms for Orthopaedic procedures. Method Prospective data was collected from consent forms for patients undergoing 6 prespecified procedures and compared to British Orthopaedic Association (BOA) guidelines for consent. We analysed how many of the risks had been documented on the form, and whether the incidence of these risk was emphasised. The data was then collated, analysed and presented at a local trauma meeting. Templates for consent were printed and inserted into consent booklets on the ward to serve as a memory aid. Data was prospectively collected again to complete the audit cycle. Results Prior to the implementation of the consent templates, 8% of consent forms mentioned all possible complications, with 12% emphasising the incidence of the main risks. Post intervention, all significant risks were listed in 29% of forms, with 33% listing the risks in a logical order and emphasising their incidence. Conclusions The process of obtaining consent is a complex but crucial component of surgical practice, with the consent form serving as an important medicolegal document. This study shows that the use of pre-printed consent templates to aid memory can improve documentation and can be adapted and individualised accordingly for each patient.

317 Audit of The Management of Ankle Fractures in The Emergency Department of Leighton Hospital

Abstract Background Ankle fractures are common presentations in the emergency department. The aim of treatment is to provide stability and restore alignment of the joint to as close as possible to the pre – injury state. The British Orthopaedic Association Audits Standards for Trauma (BOAST) guidelines provide clear recommendations for effective management of ankle fractures. Specific aspects of this guidelines that could be objectively assessed were selected for this audit to check if practices in the emergency department were meeting the national recommendations. Method Data was collected retrospectively. All patients with closed ankle fractures seen in the emergency department between 01/08/2020 and 31/08/2020 were included. Patients’ emergency department notes as well as electronic radiographic records were reviewed and analysed. Results There was 100% compliance rate for 3 of the domains assessed which include: clear documentations of mechanism of injury and clinical findings; documentation of co-morbidities of patients that can influence treatment and urgent performance of radiographs in clinically deformed ankles before manipulation.There was 75% compliance in performing and documentation of radiographs before transfer from the emergency. The worst domain was the re-assessment and documentation of neurovascular status post manipulation with only one reviewer out of five assessed documenting clearly after the process was completed. Conclusions Posters circulated in the department highlighting the findings of the audit. Furthermore, the LocSSIPs for reduction of ankle fractures was edited to include re-assessment of neurovascular status post manipulation.

360 The Impact COVID-19 Has Had on Paediatric Supracondylar Fractures: A Closed Loop Audit Demonstrating How Compliance to BOAST 11 Guidelines Has Changed in An Orthopaedic Department

AimSupracondylar fractures of the humerus in the paediatric patient is a common orthopaedic injury. Resultantly, strict guidelines were created by the British Orthopaedic Association of Standards in Trauma 11 (BOAST 11). In 2020, the COVID-19 pandemic, drastically affected the way medicine was practised. This audit aims to highlight, the extent to which compliance with BOAST 11 changed.MethodChildren with a supracondylar fracture of the humerus (Gartland 2 or 3) were included in this study. Standards from BOAST 11 were selected and the orthopaedic department were audited against these over a period of 2 years. After the first audit cycle, an information booklet was created and distributed to all doctors within the department. At the end of 2020, the department was re-audited, comparing pre-COVID results (2019) with COVID results (2020).ResultsCompliance improved within five BOAST 11 domains assessed on re-audit. With significant changes in neurovascular status being appropriately assessed and documented in clerking notes (improvement of 28%); and 2mm k-wire being used and documented in operation notes (improved by 23%). However, significant regression in results in patient’s being operated on within 24hours.ConclusionsGlobal improvement of results during the national pandemic in 2020 demonstrates that our department did not compromise patient care despite limited resources but in fact strived for clinical excellence. The reason for a regression in compliance with regards to patients not being operated on within 24hours was likely due to protect paediatric patients from unnecessary stay in hospital, in a strategy to reduce COVID-19 transmission rates.

663 A Multi-centre National Study of the Effectiveness of Virtual Fracture Clinic Management of Orthopaedic Trauma during the COVID-19 Pandemic (MAVCOV): A Cross-sectional Study Protocol

AimVirtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on demographics of injuries presenting to the VFC and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.MethodThis is a national cross-sectional cohort study comprising centres with VFC services across the United Kingdom. All consecutive adult patients assessed at VFC pre-lockdown (6 May 2019 to 19 May 2019) and at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the second wave (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation.ResultsAs of 31 October 2020, 51 hospitals with VFC services have been recruited to participate in this study.ConclusionsThe study results will identify changes in case-mix and numbers of patients managed through VFCs, due to urgent necessity, and whether this is safe and is associated with patient satisfaction to inform future clinical practice.

206 Audit of Time to Surgical Fixation of Distal Radial Fractures Compared to British Orthopaedic Association Standard for Trauma (BOAST) Guidelines at Busy District General Hospital

Abstract Aim BOAST guidelines state that intra-articular distal radial fractures should be operated on within 72 hours of injury and extra-articular distal radial fractures which require surgical management should be operated on within 7 days. The aim of this audit was to see how the orthopaedic department at a busy district general hospital compared to these guidelines. Method Retrospectively looked at operations carried out over a 10-month period. All Manipulation Under Anaesthesia, K wire and Open Reduction Internal Fixations of distal radial fractures were included. Results Over the 10-month period, 49 intra-articular and 60 extra-articular fractures were operated on. 65% of intra-articular fractures were fixed within 72 hours and 82% of extra-articular fractures were fixed within one week. Mean time from date of injury to operation was 3.88 days for intra-articular and 2.98 days for extra-articular fractures. Mean time from decision of surgery to operation was 2.32 days for intra-articular and 2.18 days for extra-articular fractures. Conclusions Clearly, the management of extra-articular fractures is closer to the standards set by BOAST guidelines. It can be difficult to establish from an x-ray whether a fracture is extending into a joint surface - this can delay the fracture clinic appointment and the operation. The difference between the mean time of injury to operation and mean time of decision of surgery to operation for intra-articular fractures show that once the decision to operate has been made, it is carried out quickly. Educating A+E and orthopaedic staff on recognising intra-articular fractures could expedite the time to surgery.

768 Impact Of COVID-19 And BOAST Standards on Surgical Management of Upper Limb Injuries in A Large Teaching Hospital

AimDuring the first peak of the COVID-19 pandemic, the BOA recommended that upper limb surgery for trauma should be avoided if possible, or performed as day-case if unavoidable, to reduce the risk of COVID-19 related negative outcomes. This audit assessed compliance with recommendations and impact on proportion of injuries managed conservatively due to COVID-19 risks, inpatient stay duration, COVID-19 infections, and corrective surgical intervention rates.MethodData was collected for all referrals to orthopaedics for upper limb fractures/dislocations at a large NHS teaching hospital in the North West over a 10-week period from April 4th to June 12th. Follow up was performed to 6 months after date of injury. Care was audited against the “British Orthopaedic Association Standard in Trauma: Management of patient with urgent orthopaedic conditions and trauma during the coronavirus pandemic”.ResultsA total of 112 patients were referred. 76% of patients were discharged from Emergency Department, with surgery indicated in 48%. Of those, 11% (n = 6) were not operated on due to COVID-19 risks and 1 patient from this group (16.7%) has required secondary corrective surgery. Surgery was completed as day-case procedure in 50%. COVID-19 swabs were not taken in 46% of referrals, 50% had a negative test and 4% positive. No patients tested positive after discharge following treatment.ConclusionsFew cases were managed conservatively based on COVID-19 risk, and only 1 patient has required secondary surgery. More upper limb injuries may be managed conservatively, as per BOAST standards, with day-case procedures better utilised as an alternative.