Summmary Clinical Audit Report Template

Registration Number / Distal Radius fractures manipulation in A&E
CA
Audit Lead / Viktoras Kubaitis / 1st Cycle/Re-Audit
Job Title / Registrar
Department / Orthopaedics
SUMMARY:
What was done?
We found 20 cases were distal radius fracture was treated by manipulation during 3 month period in our A&E. We investigated notes and radiographs of patients and finally we contacted patients by phone. We compared allowance angles with post-manipulation angles achieved in A&E.
Why was it done?
Manipulations for fractures and dislocations radiological results in our A&E were found not satisfactory in comparing with our days literature and orthopaedics understanding.
What the results show?
The post-manipulation x-rays shows that angles of distal radius are worse comparing with allowance in most cases. The results of our A&E distal radius manipulation has to be improved.
What improvements have been made?
Presentation for A&E colleagues ,Plaster making technique, with more attention to distal radius fractures manipulations and conservative treatment was prepared. The poster on A&E wall with distal radius geometrical anatomical and allowance angles was made.

DETAIL:

PROJECT AIMS / OBJECTIVE:
What were the aims and objectives of the audit
Manipulations for fractures and dislocations radiological results in our A&E were found being ambiguous and are not satisfactory in comparing with our days literature and orthopaedics understanding. Some of patients need repeated MUA in fracture clinic in next morning and it makes questions for patients. It is potential situation for time and resources waist and complains from patient side.
METHODOLOGY:
Audit criteria and standards,Source of standards e.g. NICE
Data collection e.g.prospective or retrospective
IT department found all cases were manipulations were done in A&E using special coding system (Code number 11 and 27) from 01/11/2015 till 30/01/2016. The biggest group in these manipulations were found manipulations for distal radius fractures. We investigated only manipulations which were done for distal radius fractures. Other types of procedures in A&E coded by 11 and 27 were left out of interest due to lack of cases and diversity. We investigated notes and radiographs of patients and finally we contacted patients by phone. We retrospectively found all 21 cases were distal radius fracture was treated by manipulation during 3 month period in our A&E. One lady has not got post MUA x-rays and was excluded from Audit statistics.
We used manipulation results allowance as our standard:
Dorsal tilt /degrees / Radial inclination / degrees / Shortening / mm
Anatomical angulations / 11 / 22 / 0
Before MUA / -19 / 15.5 / 4.5
Theoretical allowance / 0 / 15 / 5
After the MUA / -5.4 / 19 / 2
Our sources and references:
  1. Review of Orthopaedics. Mark D. Miller. Fifths edition. Page No 410-411;
  2. Review of Orthopaedics. Mark D. Miller. Sixth edition. Page No 523;
  3. AAOS Textbook of Orthopaedics, Page No 560-561;
  4. AAOS Guideline on The Treatment of Distal Radius Fractures;
  5. Focus On Distal radius fracture: current concepts and management. Bone & Joint Journal. 2013;
  6. Orthobullets web page

RESULTS:
What did the results show?Highlight any concerns or positives and discussion points. Highlight any need for changes in practice.
We were able to evaluate 14 notes out of 21. It is difficult to understand who done procedures and what kind of anaesthetic was used during the procedure. Doctors’ signatures and hand writing could be more eligible.
18 patients out of 21 were female. The medium age in our group was 67 (17-97).
We evaluated radiographs of the patients. One patient has not post manipulation x-rays and patient was excluded from Audit. Anatomical patterns of fractures were very not even. We used Frykman classification which we found simplest and reproducible.
There were 3 fractures involving more proximal part of ulna (more proximal than just ulnar styloid fracture) which are apparently is more unstable type of distal radius fractures something in between distal radius fractures and radius-ulna methaphysial forearm fractures.
We evaluated how much degenerative changes were before trauma. 8 wrists out of 21 had already 4 degree of degenerative osteoarthritis. 6 of them have mostly STT changes. Comminution and complexity of the fracture and Frykman type 6-7-8 were associated with 4th degree of osteoarthritis in the wrist.
One wrist had mal-union of the ulnar styloid after previous fracture. One wrist had geometrical changes post previous CL ligament tear. We found a scaphoind non-union in one wrist prior to trauma.
We evaluated how much radius styloid was inclined before procedure. Normal anatomical inclination is 22. Medium inclination after injury was 15.5 degrees (-7.7 to 25.5).
Articular level of radius and ulna has to be usually in the same level. Medium shortening of the radius after the injury was 4.5 mm (0-11). There was ulna minus in one wrist.
Normally radius articular surface of the radius is directed volary +7 to +11 degrees. Medium volar angulation after the trauma was -19 degrees (-1.7 to -44).
11 fractures out of 21 had distal fragment cominution. 10 out of 21 had inter-framental cominution. 9 out of 21 had dorsal cominution.
11 out from 21 fractures were associated with distal ulna fracture. No one patient was investigated by US for possibility of TFSS complex injury.
Two fractures were with 2 mm articular step. One of them was operated on. Four fractures had less than 1 mm articular step.
We measured radial inclination post procedure. Medium inclination was 19 degrees (0.9 to 31). Inclination difference after the procedure was found 4 degrees. Inclination was even worse after the procedure in 4 cases out of 20. There was no change in inclination in two cases.
There was medium 2 mm (0-8 mm) shortening after the procedure. The radius length was not achieved in 13 out of 19 cases. The shortening improvement after the procedure was 1.6 mm. It was worse in 2 cases. There was no difference in 6 cases.
The medium volar angulation after the procedure was -5.4 degrees. 17 cases out of 20 was did not achieved anatomical volar angulation (-20.4 to 16 degrees). The reduction allowance is 0 degrees Only 3 cases out of 20 were reduced acceptable reaching allowance limit. Medium volar angulation improvement was 13 degrees ( 0 to 33 degrees). Volar angulation was not improved in one and was even worse in 2 cases out of 20.
We have tried to contact patients on phone and to evaluate clinical result after 6 month after the treatment. 6 patients have not answered the phone at all or were not willing to speak, or we have not the number of the phone. 3 patients were too confused to speak on the phone.
The best analgesia during the MUA was found with sedation with Midasolam. But there were only two patients with that kind of analgesia and analgesia is more risky. Haematoma block was almost as comfortable as Midasolam sedation. There was one case when patient suffered from pain but most likely the injection was made not in to the fracture side directly. The highest VAS Score (Visual Analog Scale) was with Enthanox gas - 6.67 points.
No / Source of guidance or Standard / Audit Standard / Target (%) / Result (%) / Total (n)
1. /
  1. Postgraduate Orthopaedics. Second Edition
  2. Review of Orthopaedics. Mark D. Miller. Fifths edition
  3. Orthobullets web page
  4. AAOS Textbook of Orthopaedics
  5. AAOS Guideline on The Treatment of Distal Radius Fractures
  6. Focus On Distal radius fracture: current concepts and management. Bone & Joint Journal. 2013
/ Allowance of deformity after the MUA
Dorsal tilt ≥0o
Radial inclination ≥15o
Shortening ≤5 mm
Radial height ˃8
Articular step-off ≤2 mm
Lateral displacement 10 mm / 100 / 10 / 20
2. / The closed Treatment of Common Fractures. Sir John Charnley / Back slab has to have
volar angulation 15-25o.
Less than normal allows secondary displacement. Too big disturbs blood circulation / 100 / 40 / 20
3. / The closed Treatment of Common Fractures. Sir John Charnley / Back slabs summit has to be over the fracture and not over the wrist – proper three point fixation technique / 100 / 75 / 20
4. / The closed Treatment of Common Fractures. Sir John Charnley / Cast has to cover properly radius, not the ulna on AP / 100 / 35 / 20
5. / The closed Treatment of Common Fractures. Sir John Charnley / Cast has to be 3-5 mm thick. Too thin would be unstable. Too thick would be too bulky and uncomfortable / 100 / 30 / 20
6. / Injury. 2006 Mar;37(3):259-68. Epub 2006 Jan 18.
Re-displacement of paediatric forearm fractures: role of plaster moulding and padding.
Bhatia M, Housden PH. / Too much wool padding can be reason for secondary displacement post MUA. Back slab padding index has to be (PI ≤ 0.3) / 100 / 60 / 20
7. / Chess et al. (1994). Chess DG, Hyndman JC, Leahey JL, Brown DC, Sinclair AM. Short arm plaster cast for distal pediatric forearm fractures.J Pediatr Orthop.1994;14:211–3 / CI (≥0.84) / 100 / 70 / 20
8. / Common sense / MUA has to be once. Some cases were manipulated on second time / 100 / 80 / 20
We have tried to contact patients on phone and to evaluate clinical result after 6 month after the treatment. 6 patients have not answered the phone at all or were not willing to speak, or we have not the number of the phone. 3 patients were too confused to speak on the phone.
The best analgesia during the MUA was found with sedation with Midasolam. But there were only two patients with that kind of analgesia and analgesia is more risky. Haematoma block was almost as comfortable as Midasolam sedation. There was one case when patient suffered from pain but most likely the injection was made not in to the fracture side directly. The highest VAS Score (Visual Analog Scale) was with Enthanox gas - 6.67 points.
Patients feel most comfortable on Sedation by Midasolam. Haematoma block is safe and easier procedure than Sedation and even the same comfortable as with Midasolam. The patient can obey commands during the MUA on Haematoma block. Manipulation under Enthanox gas is painful and patient cannot relax properly.
Patients / Type of pain relief during the MUA / VAS average
2 / Sedation with Midasolam IV / 2.0 (0-4)
7 / Haematoma block local anaesthetic / 2.14 (0-9)
3 / Enthanox gas / 6.67 (5-8)
The final clinical - functional result was found very good 8.33 points out of 10 after the 6 month post trauma. Results of fractures distal radius were verbally compared with the function of the opposite healthy wrist. As usual with distal radius fractures final clinical results mismatch radiological pictures. Even obviously displaced fractures can heal up with satisfactory function. Nobody knows how much posttraumatic osteoarthritis can be found in far distant period in mal-united cases.
There is no exact correlation between radiological angles after the MUA and final clinical results but MUA quality has to be evaluated by improved articular angles. Allowance after the deformity improvement is described in literature obscure but our Audit shows that results of our A&E has to be improved.
OUTCOME:
What recommendations can be made from the outcome of the project?
  1. To apply more vigorous ulnar and volar deviation during the procedure and match your results with allowance.
  2. Distal ulna – radius methaphysial fractures are unstable and needs surgical stabilisation.
  3. US test for TFCC possible injury has to be used more often.
  4. To avoid Enthanox gas as single pain relieve tool for MUA.

IMPROVEMENTS ACHIEVED:
State any improvements achieved already, unless listed on action plan overleaf.
The main criteria for distal radius manipulation evaluation were found in different orthopaedic literature. The anatomical angles, allowance of post-manipulation angles and results of A&E were discussed and agreed in Audit meeting. Presentation for A&E colleagues ,Plaster making technique, with more attention to distal radius fractures manipulations and conservative treatment was prepared. The poster on A&E wall with distal radius geometrical anatomical and allowance angles was made.

Do You Intend Re-Audit Yes X No ....Action Plan completed Yes X No ....


KEY (Change Status)
  1. Recommendation agreed but not yet actioned
  2. Action in progress
  3. Recommendation fully implemented
  4. Recommendation never actioned (please state reasons)
  5. Other (please provide supporting information)

Clinical Audit Action Plan

Project Title / Distal Radius fractures manipulation in A&E
Action Plan Lead / Name: Viktoras Kubaitis / Title: Mr. / Contact: 07580598952

Group/Meeting Responsible for Monitoring Action Plan / 07/06/2016
Recommendation / Actions Required / Action by Date / Person Responsible / Changes in Practice / Change Status
To apply more vigorous ulnar and volar deviation during the procedure / Match your results with allowance / 01/10/2016 / A&E doctors
To avoid Enthanox gas as single pain relieve tool for MUA. / Use Enthanox gas only as additional relieve during manipulation / 01/10/2016 / A&E doctors
Distal ulna – radius methaphysial fractures are unstable and needs surgical stabilisation / Recognise unstable methaphysial fractures and segregate them from common distal radius fractures / 01/10/2016 / Orthopaedics
US test for TFCC possible injury has to be used more often / Suspect possible TFCC injury and refer pt to be tested by US / 01/10/2016 / Orthopaedics
Comments / Action plan
  1. To make presentation for A&E colleagues ,,Plaster making technique,, with more attention to distal radius fractures manipulations and conservative treatment.
  2. To make practical training of junior doctors and nurses in A&E.
  3. To make poster on A&E wall with distal radius geometrical anatomical and allowance angles.