Closed fifth metacarpal neck fractures: Do they need to be seen in fracture clinic? An emergency department pathway for assessment, management and criteria for fracture clinic referral

Background: In our institution patients with fifth metacarpal neck fractures used to be referred to fracture clinic. The first audit aimed to assess if the referral changes management. This resulted in implementation of new practice, followed by the re-audit and follow up. Methods: We looked at 6 months data retrospectively, followed by prospective data collection for 6 months after initiation of new practice and electronic monitoring of re-referrals. Local systems were used for data extraction. Fracture assessment included angulation, rotational deformity and whether it was an open injury. The financial department assessed the cost of each fracture clinic. Results: Thirty-six patients included in the first audit compared to 27 in the re-audit, referral rate is 97% and 78%, respectively. All injuries were closed and there was no rotational deformity. Two patients had volar angulation more than 50 degrees in the second sample but none in the first one. All patients were treated with neighbour strapping for one to two weeks and subsequent mobilisation. There were no instances of change of management with attendance at fracture clinic. Sixty percent got discharged in first appointment, compared to 50% after re-auditing. Re-referral rate is 0%. Each fracture clinic costs just over 700 pound. Conclusions: Patients with fifth metacarpal neck fractures should be managed in the ED through an agreed pathway, unless they have rotational deformity, are open or angled beyond 50 degrees in which case they should be referred to the fracture clinic or on call orthopaedic team as appropriate. This will not only avoid an unnecessary attendance at fracture clinic, but also provide cost saving.