Introduction
Rationale
Objectives
Case example I—Torus/buckle fracture | |
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A 10-year-old boy presents to the Emergency Department (ED) complaining of wrist pain after a fall from his bicycle. The patient is examined by an ED physician or Orthopaedic consultant. Radiographic imaging of the wrist reveals a torus/buckle type fracture of the distal radius, without any angulation | |
Treatment before implementation of direct discharge | Treatment after implementation of direct discharge |
A plaster cast/splint is applied in the ED A follow-up appointment is scheduled in the fracture clinic in 7 days After 7 days, the cast/splint is removed. Bandage and a sling are applied. Parents are instructed to remove the bandage in a few days as pain allows. No further imaging is performed The patient is then discharged from follow-up with instructions regarding sports, etc | A removable wrist orthosis is applied in the ED Verbal instructions are provided in the ED with regard to the injury, recovery, when to remove the orthosis, when to contact the hospital, etc This is also summarized in a discharge leaflet and/or smartphone application No follow-up appointments are scheduled It is allowed to remove the orthosis e.g., to take a shower, and parents are instructed to permanently remove the orthosis after 7 days If pain does not allow, then the orthosis can be used for another week A special telephone helpline is available in case of any questions or concerns. If necessary, a face-to-face follow-up appointment is scheduled |
Case example II—Fifth metatarsal fracture | |
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A 50-year-old woman presents to the Emergency Department (ED) complaining of pain on the lateral side of her foot after missing the last step of the stairs. The patient is examined by an ED physician or Orthopaedic consultant. Radiographic imaging of the foot reveals a non-displaced fracture of the base of the fifth metatarsal bone (i.e., Zone 1/Dancer’s fracture) | |
Treatment before implementation of direct discharge | Treatment after implementation of direct discharge |
A plaster cast/splint is applied in the ED A follow-up appointment is scheduled in the fracture clinic in 7 days After 7 days, the cast/splint is removed and a new splint is applied. The patient is scheduled for another appointment in 5 weeks After 5 weeks, the splint is removed and radiographic imaging is performed. The radiograph shows first signs of bone healing Based on local protocols and physician preference/examination, the patient is then either; discharged from further follow-up with instructions regarding sports, etc reviewed again in a few weeks to assess functional outcome and perform radiographic imaging | A removable orthosis (walker boot) is applied in the ED Verbal instructions are provided in the ED with regard to the injury, recovery, when to remove the walker, when to contact the hospital etc This is also summarized in a discharge leaflet and/or smartphone application No follow-up appointments are scheduled It is allowed to remove the orthosis e.g., to take a shower, patients are instructed to use the walker for 6 weeks and wear a supportive shoe A special telephone helpline is available in case of any questions or concerns. If necessary, a face-to-face follow-up appointment is scheduled, and/or imaging is performed |
Methods
Protocol and registration
Eligibility criteria
Logistic outcomes
Financial outcomes
Patient outcomes
Information sources
Search
Study selection
Data collection process
Data items
Risk of bias in individual studies
Summary measures
Synthesis of results
Results
Study selection
Study characteristics
Study details | Sample size; n | Study population | Outcomes | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
First author | Country | Year | Design | Control | Intervention | Injuries studied | Described eligibility criteria for DD | Population | D | L | € | F | S | AO | Period; m |
Comparative | |||||||||||||||
Abdelmalek [10] | England | 2015 | RCSPPP | 36 | 27 | 5MC neck Fx | Angulation < 50°, no rotational deformity | A + P | + | + | − | − | − | − | 6 vs. 6 |
Bansal [11] | England | 2007 | PCSPPP | 40 | 38 | 5MC neck Fx | Angulation < 70°, no rotational deformity, no delay (< 1w) | ≥ 16y | − | + | − | + | + | − | NR |
Ferguson [12] | Scotland | 2015 | RPPRCS | 279 | 339 | 5MT Fx | Not clearly defined | A + P | + | + | − | − | − | + | 12 vs. 12 |
Hamilton [13] | England | 2013 | RCT | 158 | 159 | Stable forearm Fx | Torus/greenstick: < 15° angulation; SH I/II: < 5 mm displaced | P ≥ 2y | − | + | + | + | + | − | 34 |
Kelly [14] | Ireland | 2019 | RPPRCS | NR | 247 | Multiple | Not clearly defined | A + P | + | − | − | − | − | − | 6 vs. 6 |
Khan [15] | Ireland | 2007 | RCT | 48 | 69 | Torus Fx distal radius | Not clearly defined, described as ‘stable’ | P | − | − | − | − | + | − | 3 |
Mackenzie [9] | Scotland | 2018 | RPPCS | 108 | 88 | 5MC Fx | Isolated extra-articular Fx | A + P ≥ 13y | − | + | + | + | + | + | 6 vs. 6 |
111 | 87 | 5MT Fx | Any | A + P ≥ 13y | − | + | + | + | + | + | 6 vs. 6 | ||||
118 | 114 | Radial head/neck Fx | Mason type 1 and 2 | A + P ≥ 13y | − | + | + | + | + | + | 6 vs. 6 | ||||
Matthews [16] | England | 2014 | RPPCS | 55 | 23 | Clavicle Fx | Isolated single fragment midshaft Fx | P 1-15y | + | − | − | − | + | − | 10 vs. 3 |
Seewoonarain[17] | England | 2019 | RPPCS | 39 | 44 | Torus Fx distal radius | No associated ulnar styloid Fx | P < 16y | + | + | + | − | − | − | 6. vs 6 |
Vardy [8] | Scotland | 2014 | RPPCS | 2840 | 6385 | All not requiring immediate inpatient treatment | Not clearly defined, included 5MC neck, paediatric greenstick/torus, clavicle, mallet finger, radial head, 5MT Fx | A + P | + | − | − | − | − | − | 12 vs. 12 |
Non-comparative | |||||||||||||||
Bhattacharyya[18] | Scotland | 2017 | RCS | 138 | Clavicle Fx | Not clearly defined, mostly Robinson 2a1 and 3a1 | A + P | + | + | − | + | − | + | 12 | |
Breathnach [19] | Ireland | 2018 | RCS | 157 | ‘Orthopaedic Fx’ | Not clearly defined, includes buckle Fx/STI of hand, foot, ankle | A + P | + | − | − | − | − | + | 1.5 | |
Brogan [20] | England | 2017 | CS | 663 | Suspected 5MT Fx | All 5MT Fx, but ‘Jones’ Fx’ based on clinician’s decision | A + P | + | + | − | − | − | + | 24 | |
Brooksbank[21] | Scotland | 2014 | PCS | 47 | Mallet finger | Not clearly defined | NR | + | + | − | + | + | − | 12 | |
Callender [22] | Ireland | 2015 | RCS | 119 | Wrist torus Fx | Not clearly defined | P | − | + | + | − | − | + | 12 | |
Evans [23] | England | 2018 | PCS | 291 | Hand and wrist injuries | ‘Simple tuft, 5MC neck, minor avulsion, volar plate and STI’ | A + P | + | − | − | − | − | + | 4.5 | |
Gamble [24] | Scotland | 2015 | RCS | 167 | 5MC Fx | Not clearly defined | A | − | + | − | + | + | − | 6 | |
Gleeson [25]—I | NZ | 2016 | RCS | 61 | Torus Fx radius/ulna; clavicle Fx | Torus: < 15° angulation; Clavicle: isolated Fx with bone contact | P > 1y | − | + | + | - | + | − | 12 | |
Gleeson [26]—II | NZ | 2016 | RCS | 33 | 5MC neck Fx; 5MT base Fx; Ankle Fx, Weber type A | 5MC: < 60° angulation, no rotation; 5MT: Zone 1 < 2 mm displaced, < 10% angulation; Weber A: < 4 mm displaced, fragment < 5 mm | NR | − | − | + | − | − | − | 9 | |
Ibrahim [27] | Scotland | 2018 | CS | 100 | Acute closed STI/bony hand injuries | Not clearly defined, but excl. isolated carpal and wrist Fx | NR | + | − | − | − | − | + | 1.5 | |
Jayaram [28] | Scotland | 2014 | RCS | 182 | Radial head/neck Fx | Unilateral, Mason type 1 or 2 or fatpad sign, no other injuries | NR | + | + | − | − | − | + | 12 | |
Jenkins [2] | Scotland | 2014 | RCS | 6385 | 5MT, 5MC, distal radius, torus, radial head Fx, mallet finger, child clavicle Fx | Not clearly defined, described as ‘simple, self-limiting stable Fx’ | A + P | + | − | − | − | − | − | 12 | |
Little [29] | England | 2020 | PCS | 3709 | Hand/wrist injuries | Stable STI/bony injury, no significant swelling or ROM problems | A + P | + | − | − | + | + | − | 21 | |
O’Reilly [30] | Ireland | 2019 | CS | 2704 | Simple 5MC, 5MT, clavicle, radial head or torus Fx, mallet finger | Not clearly defined: ‘simple injuries’, mallet finger: no bony injury | A + P | + | − | − | − | − | − | 19 | |
Robinson [31] | England | 2017 | PCS | 229 | MC, phalanx hand, distal radius/ulna, elbow, clavicle, metatarsal, lateral malleolus Fx | Metacarpal: < 60° angulation, no rotational deformity; phalanx: minor avulsion, wrist: undisplaced or torus, elbow: undisplaced/ fatpad (> 5y); clavicle: un/minor displaced, metatarsal: undisplaced; lateral malleolus: undisplaced (> 5y) | P | - | + | − | − | − | + | 6 | |
White [1] | Scotland | 2017 | RCS | 12,069 | All patients with musculoskeletal injuries | Mallet finger with no bony injury, 5MC neck, radial head/neck Mason type I or II, 5MT base Fx or Fx of lesser toe | A + P | + | − | − | − | − | − | 12 |
Risk of bias within studies
Results of individual studies
Logistic outcomes
Study | Injury | DD cohort size; n | DD rate; % | Relative to all patients with |
---|---|---|---|---|
Comparative | ||||
Abdelmalek [10] | 5MC neck Fx | 6 | 22.2 | 5MC neck fractures |
Bansal [11] | 5MC neck Fx | 38 | n/a | – |
Ferguson [12] | 5MT Fx | 280 | 82.6 | 5MT fractures |
Hamilton [13] | Paediatric forearm Fx | 159 | n/a | – |
Kelly [14] | Multiple | 45 | 18.2 | Minor trauma injuries |
Khan [15] | Torus Fx wrist | 69 | n/a | – |
Mackenzie [9] | 5MC Fx | 88 | n/a | – |
5MT Fx | 87 | n/a | – | |
Radial head/neck Fx | 114 | n/a | – | |
Matthews [16] | Paediatric clavicle Fx | 18 | 78.3 | Paediatric zone 2 (midshaft) clavicle fractures |
Seewoonarain [17] | Torus Fx wrist | 33 | 75.0 | Torus fractures of the distal radius |
Multiple | 3802 | 59.5 | Musculoskeletal injuries in the ED not requiring immediate admission | |
Non-comparative | ||||
Bhattacharyya [18] | Clavicle Fx | 62 | 44.9 | Clavicle fractures |
Breathnach [19] | Multiple | 42 | 26.8 | Any type of fracture |
Brogan [20] | 5MT Fx | 499 | 75.3 | 5MT fractures |
Brooksbank [21] | Mallet finger | 46 | 97.9 | Mallet finger injuries |
Callender [22] | Torus Fx wrist | 119 | n/a | – |
Evans [23] | Hand/wrist injuries | 54 | 18.6 | Hand/wrist injuries |
Gamble [24] | 5MC Fx | 167 | n/a | – |
Gleeson [25]—I | Torus Fx wrist; paediatric clavicle Fx | 61 | n/a | – |
Gleeson [26]—II | 5MC neck, 5MT base, Weber A Fx | 33 | n/a | – |
Ibrahim [27] | Hand/wrist injuries | 38 | 38.0 | Hand/wrist injuries |
Jayaram [28] | Radial head/neck Fx | 182 | 90.1 | Mason type 1 or 2 radial head/neck fractures |
Little [29] | Hand/wrist injuries | 968 | 26.1 | Hand injuries |
O’Reilly [30] | Multiple | 901 | 33.3 | Musculoskeletal injuries in the ED |
Robinson [31] | Multiple paediatric | 229 | n/a | – |
White [1] | Multiple | 3222 | 26.7 | Musculoskeletal injuries in the ED |
Study | Injury | Number of appointments; mean | Mean reduction | Returned after DD | Repeat radiographic images; mean | ||
---|---|---|---|---|---|---|---|
Control | DD | Rate; % | Control | DD | |||
Comparative | |||||||
Abdelmalek [10] | 5MC neck Fx | 1.33 | 0.0 | 1.33 | 0.0 | NR | 0.0 |
Bansal [11] | 5MC neck Fx | 1.83 | 0.05 | 1.78 | 5.3 | NR | NR |
Ferguson [12] | 5MT Fx | 1.76 | < 0.30* | 1.46 | 2.5 | NR | NR |
Hamilton [13] | Paediatric forearm Fx | 1.05 | 0.02 | 1.03 | 1.3 | NR | NR |
Mackenzie [9] | 5MC Fx | 1.08 | 0.08 | 1.00 | NR | 0.4 | 0.06 |
5MT Fx | 2.08 | 0.33 | 1.75 | NR | 0.3 | 0.13 | |
Radial head/neck Fx | 1.25 | 0.22 | 1.03 | NR | 1.1 | 0.31 | |
Seewoonarain [17] | Torus Fx wrist | 1.00 | 0.0 | 1.00 | 0.0 | 1.0 | 0.0 |
Non-comparative | |||||||
Bhattacharyya [18] | Clavicle Fx | 0.02 | 1.6 | NR | |||
Brogan [20] | 5MT Fx | < 0.17** | NR | NR | |||
Brooksbank [21] | Mallet finger | NR | 19.4 | NR | |||
Callender [22] | Torus Fx wrist | 0.0 | 0.0 | 0.0 | |||
Gamble [24] | 5MC Fx | 0.0 | 0.0 | 0.0 | |||
Gleeson [25]—I | Torus Fx wrist; clavicle Fx | 0.0 | 0.0 | 0.0 | |||
Jayaram [28] | Radial head/neck Fx | NR | 1.1 | NR | |||
Robinson [31] | Multiple | NR | 9.2 | NR |
Financial outcomes
Study | Injury | How were costs calculated | Costs per patient before DD | Costs per patient after DD | Δ/patient; € | Δ/patient; % | Sig. |
---|---|---|---|---|---|---|---|
Comparative | |||||||
Hamilton [13] | Paediatric forearm Fx | Costs resulting from clinic visits, MIU visits, GP visits, telephone contacts, plaster room contact, use of immobilization materials | Mean GBP 261.04 | Mean GBP 160.48 | − €11,157 | − 38.5% | < 0.001 |
Mackenzie [9] | 5MC Fx | National Health Service secondary care cost analysis, including staffing, operation and radiology costs | Median GBP 139.83 (86.1–288.69) | Median GBP 12.17 (0.58–21.02) | − €14,164 | − 91.3% | NR |
5MT Fx | Similar | Median GBP 297.74 (210.39–385.15) | Median GBP 113.35 (4.48–316.72) | − €204,58 | − 61.9% | NR | |
Radial head/neck Fx | Similar | Median GBP 167.11 (127.16–257.23) | Median GBP 28.97 (9.82–44.23) | − €15326 | − 82.7% | NR | |
Seewoonarain [17] | Torus Fx wrist | Costs resulting from clinic visits and material costs, staffing costs | Mean GBP 163.82 | Mean GBP 101.60 | − €6903 | − 38.0% | NR |
Non-comparative | |||||||
Gleeson [25]—I | Torus Fx wrist; Paediatric clavicle Fx | Financial savings as quantified by business analyst. Unclear description of exact calculation | NZD − 379.88 per clavicle visit NZD − 223.88 per buckle visit | − €21,028 − €12,993 | –a –a | ||
Gleeson [26]—II | Multiple | Financial savings as quantified by business analyst. Unclear description of exact calculation | NZD -379.88 per visit | − €21,028 | –a | ||
Callender [22] | Torus Fx wrist | Simple estimation of costs from outpatient clinic visits and soft cast material costs, compared to estimation of previous situation | Mean GBP 162.11 | Mean GBP 5.50 | − €17,376 | − 96.6% |
Patient outcomes
Questionnaire | Study | Injury | Assessment | Control | DD | Sig. | ||||
---|---|---|---|---|---|---|---|---|---|---|
Reported as | How | When | Score | Resp. rate; % | Score | Resp. rate; % | ||||
Comparative | ||||||||||
DASH | Bansal [11] | 5MC neck Fx | Mean score | Phone | 12 w | 8.1 (SD 6.0) | NR | 6.8 (SD 4.9) | NR | NS |
FADI | Mackenzie [9] | 5MT Fx | Median score | NR | 6 m | 100 (95–100) | 66.0 | 100 (97–100) | 80.0 | NS |
CHAQ | Hamilton [13] | Paediatric forearm Fx | Mean change index score | Post | 4 w | − 0.48 (SD 4.87) | 67.1 | 0.48 (SD 4.02) | 79.2 | NS |
QuickDASH | Mackenzie [9] | Radial head/neck Fx | Median score | NR | 6 m | 0.0 (0–2.3) | 80.0 | 0.0 (0–4.5) | 80.0 | NS |
Mackenzie [9] | 5MC Fx | Median score | NR | 6 m | 0.0 (0–7.9) | 21.0 | 0.0 (0–0) | 53.0 | 0.001 | |
Non-comparative | ||||||||||
QuickDASH | Gamble [24] | 5MC Fx | Median score | Post/phone | > 1 y | 2.3 (0 to 6.8) | 80.6 | |||
Brooksbank [21] | Mallet finger | Median score | Post | 1 y | 2.27 (0 to 4.55) | 77.0 | ||||
Bhattacharyya [18] | Clavicle Fx | Mean score | Post | 1 y | 16.1 (SD 25.2) | 71.0 | ||||
QuickDASH modules Disability; Work; Sport | Little [29] | Hand/wrist injuries | Median module score | Post/phone | > 6 m | D: 4.4 (0–24) W: 14 (0–32) S: 14 (0–32) | 92.0 89.0 38.0 |
Experience measure | Study | Injury | Assessment | Control | DD | Sig. | ||||
---|---|---|---|---|---|---|---|---|---|---|
Assessed by | How | When | Score | Resp. rate; % | Score | Resp. rate; % | ||||
Comparative | ||||||||||
Satisfaction with treatment | Bansal [11] | 5MC neck Fx | Scale 1 (VD) to -10 (VS) | Phone | 12 w | 5.1 (SD 1.9) | NR | 7.0 (SD 1.4) | NR | 0.04 |
Hamilton [13] | Paediatric forearm Fx | Seven domain satisfaction, Likert | Post | 6 m | ‘No difference’ | 93.7 | ‘No difference’ | 88.1 | NS | |
Matthews [16] | Clavicle Fx | NR | NR | > 6 m | NR | – | Majority satisfied | 100 | NR | |
Khan [15] | Torus Fx wrist | Scale 1 (VD) to -10 (VS) | Phone | 4–5 w | Highly satisfied | 100 | ‘Highly satisfied’ | 100 | NR | |
Mackenzie [9] | 5MC, 5MT, RHFx | Yes/no question | NR | 6 m | 95% S | 56.4 | 98% S | 72.3 | NR | |
Non-comparative | ||||||||||
Satisfaction with treatment | Gamble [24] | 5MC Fx | Likert scale | Post/phone | > 1 y | 84.9% VS or S | 59.0 | |||
Gleeson [25]—I | Torus Fx, clavicle Fx | Likert scale | Phone | 3–6 w | 100% VS or S | 45.9 | ||||
Brooksbank [21] | Mallet finger | Likert scale | Post | 1 y | 100% VS or S | 77.0 | ||||
Little [29] | Hand/wrist injuries | Likert scale | Post/phone | > 6 m | 99.3% VS or S | 94.0 |
Outcome | Study | Injury | Assessment | Outcome; n (%), reason if available | Sig. | ||
---|---|---|---|---|---|---|---|
How | When | Control | DD | ||||
Comparative | |||||||
Non-union rate | Ferguson [12] | 5MT Fx | EPR evaluation | > 1 y | 1 (0.4), zone 1 fracture* | 2 (0.6), one Jones, one proximal diaphyseal fracture* | NS |
Mackenzie [9] | 5MC Fx | EPR evaluation | 3 y | 0 (0.0) | 0 (0.0) | – | |
5MT Fx | EPR evaluation | 3 y | 1 (0.9) | 2 (2.3) | NR | ||
Radial head/neck Fx | EPR evaluation | 3 y | 0 (0.0) | 0 (0.0) | – | ||
Secondary surgery rate | Ferguson [12] | 5MT Fx | EPR evaluation | > 1 y | 3 (1.1), 1 non-union, 2 refracture* | 2 (0.6), both non-union* | NS |
Mackenzie [9] | 5MC Fx | EPR evaluation | 3 y | 0 (0.0) | 0 (0.0) | – | |
5MT Fx | EPR evaluation | 3 y | 1 (0.9, non-union) | 2 (2.3), both non-union | NR | ||
Radial head/neck Fx | EPR evaluation | 3 y | 0 (0.0) | 0 (0.0) | – | ||
Non-comparative | |||||||
Non-union rate | Brogan [20] | 5MT Fx | EPR and PACS | > 6 m | 8 (1.2) Jones type* 5 (0.75) asymptomatic zone 1 fractures in DD cohort | ||
Secondary surgery rate | Bhattacharyya[18] | Clavicle Fx | EPR evaluation | 1y | 0 (0.0) | ||
Brogan [20] | 5MT Fx | EPR and PACS | > 6 m | 1 (0.15), symptomatic non-union | |||
Jayaram [28] | Radial head/neck Fx | NR | > 6 m | 1 (0.5) in DD cohort, malunion Mason II fracture | |||
Other | Breathnach [19] | Multiple | NR | 18–24 m | 1 (0.64) poor clinical outcome, referred to physiotherapist | ||
Callender [22] | Torus Fx wrist | NR | NR | ‘No adverse events or clinically significant complications’ | |||
Evans [23] | Hand/wrist injuries | Survey | NR | ‘No complications of treatment’ | |||
Ibrahim [27] | Hand injuries | Hand therapist | NR | ‘No adverse outcomes’ | |||
Robinson [31] | Multiple | EPR review | > 1 m | ‘No serious adverse outcomes’ |