Recommendations for research
The guideline committee has made the following recommendations for research.
Is CT scanning in addition to initial plain film X‑ray clinically effective and cost effective for planning surgical treatment of unstable/displaced ankle fractures compared with plain film X‑ray alone?
Ankle fractures are common and affect a significant number of people every year. Outcomes following surgery are important for patients' long-term function and quality of life, and may also be associated with additional cost if another operation is needed. It is important to know whether adding CT scanning to plain film X‑ray improves outcomes following surgery and is cost effective.
What is the clinical and cost effectiveness of virtual new patient fracture clinics compared with next-day consultant-led face-to-face clinics in people presenting with non-complex fractures in the emergency department and thought to need an orthopaedic opinion?
Currently many people with fractures are asked to attend a next-day clinic led by a consultant, although it is believed that a virtual clinic may be at least as effective. If this is the case, face-to-face clinics may be an unnecessary use of time and resources for both patients and the NHS. Firm evidence of clinical and cost effectiveness is needed before virtual clinics can be introduced as part of a change in service structure.
For patients with displaced fractures of the distal radius, is manipulation with real-time image guidance more clinically and cost effective than manipulation without real-time image guidance?
In a large minority of patients with a distal radius fracture, the bone fragments are displaced and need manipulation and reduction into an anatomical position. Currently in the NHS, most manipulations for distal radius fractures are performed in the emergency department without real-time image guidance. It is believed that image guidance may be important, but despite hundreds of people having manipulation for these fractures in the emergency department each day, there are no high-quality studies in this area.
What is the most clinically effective and cost-effective strategy for weight-bearing in people who have had surgery for internal fixation of an ankle fracture?
In the NHS, open reduction and internal fixation of the ankle is often performed. Currently there is variation in the advice about mobilisation and weight-bearing given to people who have had this done. There is uncertainty as to whether people should be advised to immediately start unrestricted weight-bearing as tolerated or to wait a number of weeks.
What is the clinical effectiveness and cost effectiveness of no treatment for torus fractures of the distal radius in children compared with soft splints, removable splints or bandages?
Torus fractures of the distal radius are among the most common fractures in children but management varies widely between immediate discharge from the emergency department to repeated outpatient reviews with casting and imaging. These fractures result from trauma to growing bones and account for an estimated 500,000 emergency department attendances a year in the UK. Current treatment often involves application of a bandage, or a removable cast or a soft cast, with review in outpatient clinics and repeated X‑ray imaging. This is despite anecdotal evidence that treatment with simple analgesia and immediate discharge from the emergency department is safe and effective. There have been no studies comparing current treatments with no intervention in children with torus fractures. A randomised controlled trial is needed to evaluate the clinical and cost effectiveness of no treatment compared with soft splints, removable splints or bandages.