A physiotherapy led clinic in the Emergency Department for suspected scaphoid fractures

Purpose

The purpose of the service evaluation was to assess the management of suspected scaphoid fractures in a new physiotherapy-led scaphoid clinic and to compare the standard of care for suspected scaphoid fractures for patients who were previously being managed by the ED doctors in an ED Consultant clinic. Historically, the suspected scaphoid fractures were being managed in the ED Consultant clinic. After a period of observation and supervised practice, the Advanced Physiotherapy Practitioner implemented a new scaphoid clinic in Dec 2015. A revised pathway for secondary imaging and management was discussed an agreed with the ED Consultants and Consultant Radiologists.

Approach

Data for the new Scaphoid clinic was collected prospectively from the 15th Dec 2015 to 30th June 2016. Data included age, sex, hand dominance, duration until scaphoid clinic, clinical scaphoid signs, referral for secondary imaging, non-attendance for imaging and overall outcome. The data was then compared to information obtained retrospectively for patients being managed over the same period, 12-months earlier, in the ED Consultant clinic.

Outcomes

A total of 66 patients were seen in the Scaphoid clinic from 15th Dec 2015 to 30th June 2016. 39 (59%) females and 27 (41%) males had an average age of 39 years of age. The average days to follow up in the clinic was 14 days. 30 and 36 patients had a dominant and non-dominant hand injury, respectively. Of the 66 patients, 33 (50%) were sent for secondary imaging (14 MRI, 17 Isotope and 2 repeat X-Ray). The results showed that 11 patients (33%) had confirmed fractures (5 Scaphoid, 5 Other Carpal, 1 Distal Radius). This was compared to 66 patients that were seen previously in the ED Consultant clinic, of which 36 (55%) were referred for further imaging. Of these 36 patients, 12 (33%) had confirmed fractures (No scaphoid, 8 other carpal, 4 distal radius). 9 patients (25%) and 6 patients (18%) failed to attend their scan appointment when referred from the ED Consultant clinic and Scaphoid clinic, respectively.

Cost and savings

The same number of patients were seen in the physiotherapy-led Scaphoid clinic to that of the ED Consultant clinic over the same period, with a similar number (36 from ED Consultant, 33 from Scaphoid Clinic) of patients being referred for secondary imaging. Of those patients who had additional scans, the results show identical number of fractures being detected (33%), although the fracture distribution differed slightly. There was a reduced number of non-attendance for their scan appointment for those patients referred from the Scaphoid clinic. The new physiotherapy-led Scaphoid clinic has demonstrated that the standard of care and referral for secondary imaging for suspected scaphoid fractures is the same to that of patients being managed by an ED Consultant.

Implications

With increasing pressures, demands and waiting times in the ED, the scaphoid clinic has demonstrated that patient with these injuries are being effectively managed by an Advanced Physiotherapy Practitioner, thus freeing up time for the ED Consultants and doctors to manage acutely unwell patients.

Fund acknowledgements

No additional funding was received during the service redesign and implementation.

Additional notes

This work was presented at Physiotherapy UK 2018.