Orthopaedic trauma patients' experiences with emergency department care and follow-up through Virtual Fracture Care review: a qualitative study.

OBJECTIVES: This study aimed to identify factors influencing orthopaedic trauma patients' experiences and satisfaction with emergency department (ED) care and follow-up through Virtual Fracture Care (VFC) review workflow. DESIGN: This study employed an explorative, descriptive, qualitative design using individual, semistructured interviews. SETTING: An urban level 2 trauma centre and teaching hospital in Amsterdam, the Netherlands. PARTICIPANTS: Eligible patients were Dutch-speaking or English-speaking orthopaedic trauma patients, aged 18 years or above, who visited the hospital's ED between June and September 2022, and were treated through VFC review workflow. Exclusion criteria were: reason for follow-up other than injury, eye/motor/verbal score <15 at ED admission, follow-up treatment in another hospital, treatment initiated in another hospital, acute hospital admission (<24 hours). Twenty-three patients were invited for participation, of whom 15 participated and were interviewed. RESULTS: Several influential factors contributed to seven generic themes: (1) waiting times, (2) information provision, (3) healthcare professional communication, (4) care expectations, (5) care coordination, (6) care environment and (7) patient condition. Overall, participants were satisfied with received care. Interpersonal skills of healthcare professionals, and timing and content of provided information were specifically valued. Additionally, patients stated that their needs in the ED differed from those after ED discharge, and appreciated the way the VFC review workflow addressed this. Points of improvement included more active involvement of patients in the care process and prevention of inconsistent instructions by different healthcare professionals. CONCLUSIONS: Patient experiences with ED care and VFC review follow-up are influenced by factors categorised into seven themes. The VFC review workflow effectively addresses these factors, leading to positive feedback. Recommendations for healthcare professionals include anticipating evolving post-ED information needs, engaging patients early to provide clarity about the care process, involving them in treatment decisions and expanding information provision across the entire care pathway.

Health Care Professionals' Experiences With a Mobile Self-Care Solution for Low Complex Orthopedic Injuries: Mixed Methods Study.

BACKGROUND: To cope with the rising number of patients with trauma in an already constrained Dutch health care system, Direct Discharge (DD) has been introduced in over 25 hospitals in the Netherlands since 2019. With DD, no routine follow-up appointments are scheduled after the emergency department (ED) visit, and patients are supported through information leaflets, a smartphone app, and a telephone helpline. DD reduces secondary health care use, with comparable patient satisfaction and primary health care use. Currently, little is known about the experiences of in-hospital health care professionals with DD. OBJECTIVE: The aim of this study was to explore the experiences of health care professionals with the DD protocol to enhance durable adoption and improve the protocol. METHODS: We conducted a mixed methods study parallel to the implementation of DD in 3 hospitals. Data were collected through a preimplementation survey, a postimplementation survey, and semistructured interviews. Quantitative data were reported descriptively, and qualitative data were reported using thematic analysis. Outcomes included the Bowen feasibility parameters: implementation, acceptability, preliminary efficacy, demand, and applicability. Preimplementation expectations were compared with postimplementation experiences. Health care professionals involved in the daily clinical care of patients with low-complex, stable injuries were eligible for this study. RESULTS: Of the 217 eligible health care professionals, 128 started the primary survey, 37 completed both surveys (response rate of 17%), and 15 participated in semistructured interviews. Health care professionals expressed satisfaction with the DD protocol (median 7.8, IQR 6.8-8.9) on a 10-point scale, with 82% (30/37) of participants noting improved information quality and uniformity and 73% (27/37) of patients perceiving reduced outpatient follow-up and imaging. DD was perceived as safe by 79% (28/37) of participants in its current form, but a feedback system to reassure health care professionals that patients had recovered adequately was suggested to improve DD. The introduction of DD had varying effects on workload and job satisfaction among different occupations. Health care professionals expressed intentions to continue using DD due to increased efficiency, patient empowerment, and self-management. CONCLUSIONS: Health care professionals perceive DD as an acceptable, applicable, safe, and efficacious alternative to traditional treatment. A numerical in-app feedback system (eg, in-app communication tools or recovery scores) could alleviate health care professionals' concerns about adequate recovery and further improve DD protocols. DD can reduce health care use, which is important in times of constrained resources. Nonetheless, both advantages and disadvantages should be considered while evaluating this type of treatment. In the future, clinicians and policy makers can use these insights to further optimize and implement DD in clinical practice and guidelines.

The Amsterdam Wrist Rules to reduce the need for radiography after a suspected distal radius fracture: an implementation study.

PURPOSE: While most patients with wrist trauma are routinely referred for radiography, around 50% of these radiographs show no fracture. To avoid unnecessary radiographs, the Amsterdam Wrist Rules (AWR) have previously been developed and validated. The aim of the current study was to evaluate the effect of the implementation of the AWR at the Emergency Department (ED). METHODS: In a before-and-after comparative prospective cohort study, all consecutive adult patients with acute wrist trauma presenting at the ED of four hospitals were included. Primary outcome was the number of wrist radiographs before and after implementation of the AWR. Secondary outcomes were the number of clinically relevant missed fractures, the overall length of stay in the ED, physician compliance regarding the AWR, and patient satisfaction and experience with the care received at the ED. RESULTS: A total of 402 patients were included. The absolute reduction in wrist radiographs after implementation was 15% (p < 0.001). One clinically irrelevant fracture was missed. Non-fracture patients without wrist radiography due to the AWR spent 34 min less time in the ED compared with non-fracture patients who had a wrist radiograph (p = 0.015). The physicians adhered to the AWR in 36% of patients. Of all patients who did not receive a radiographic examination of the wrist, 87% were satisfied. CONCLUSION: Implementation of the AWR safely reduces the amount of wrist radiographs in selected patients and consequently reducing the length of stay in the ED.

Amsterdam wrist rules: a clinical decision aid.

BACKGROUND: Acute trauma of the wrist is one of the most frequent reasons for visiting the Emergency Department. These patients are routinely referred for radiological examination. Most X-rays however, do not reveal any fractures. A clinical decision rule determining the need for X-rays in patients with acute wrist trauma may help to percolate and select patients with fractures. METHODS/DESIGN: This study will be a multi-center observational diagnostic study in which the data will be collected cross-sectionally. The study population will consist of all consecutive adult patients (≥18 years) presenting with acute wrist trauma at the Emergency Department in the participating hospitals. This research comprises two components: one study will be conducted to determine which clinical parameters are predictive for the presence of a distal radius fracture in adult patients presenting to the Emergency Department following acute wrist trauma. These clinical parameters are defined by trauma-mechanism, physical examination, and functional testing. This data will be collected in two of the three participating hospitals and will be assessed by using logistic regression modelling to estimate the regression coefficients after which a reduced model will be created by means of a log likelihood ratio test. The accuracy of the model will be estimated by a goodness of fit test and an ROC curve. The final model will be validated internally through bootstrapping and by shrinking it, an adjusted model will be generated. In the second component of this study, the developed prediction model will be validated in a new dataset consisting of a population of patients from the third hospital. If necessary, the model will be calibrated using the data from the validation study. DISCUSSION: Wrist trauma is frequently encountered at the Emergency Department. However, to this date, no decision rule regarding this type of trauma has been created. Ideally, radiographs are obtained of all patients entering one of the participating hospitals with trauma to the wrist. However, this is ethically and logistically not feasible and one could argue that patients, for whom no radiography is required according to their physician, are not suspected of having a distal radius fracture and thus are not part of the domain. TRIAL REGISTRATION: This study is registered at the Netherlands Trial Register (NTR 2544) and was granted permission by the Medical Ethical Committee of the Academic Medical Center Amsterdam on 06-01-2011.

Complete Avulsion of the Pectoralis Major Tendon: a Case Report.

Rupture of the pectoralis major muscle is a rare injury, usually occurring during sports activities or after direct trauma. This article describes the clinical presentation, diagnostic tools and treatment of a patient with a complete avulsion of the pectoralis major tendon.

Internal fracture fixation using the Stoppa approach in pelvic ring and acetabular fractures: technical aspects and operative results.

BACKGROUND: The ilioinguinal approach is well established for the treatment of pelvic fractures. As an alternative, the modified Stoppa approach can be used to expose pelvic and acetabular fractures. We describe our experience with this approach in patients with pelvic and acetabular fractures with respect to fracture reduction, technical aspects, and the incidence of intra- and postoperative complications. METHODS: This retrospective study describes a series of 25 consecutive patients where a modified Stoppa approach was used for pelvic or acetabular fracture fixation. RESULTS: Fifteen patients with acetabular fractures, six patients with a pelvic ring injury not involving the acetabular joint and four patients with a combined fracture were operated through a Stoppa approach. Nine patients had a total of 13 complications, none of which required reoperation. Anatomic or satisfactory reduction was achieved in 95% of the acetabular fractures. Pelvic ring fractures had an anatomic (displacement <1 cm) postoperative result in all 10 cases. CONCLUSION: The modified Stoppa approach allows an adequate exposure and good postoperative results for treatment of pelvic ring fractures and acetabular fractures that are eligible for an anterior approach.

Rupture of the tibialis anterior tendon.

Rupture of the tibialis anterior tendon is rare. There is usually a delay in diagnosis, probably because it is an uncommon entity. Diagnosis is easy however, and recovery with surgical treatment is satisfactory if repair is performed within the first three months following the initial trauma. After this period of time, an operation is less likely to be effective. We report a case with successful outcome following surgical repair of a ruptured tibialis anterior tendon.