The ED Direct Discharge process covers the following injuries:
- 5th Metacarpal Neck fracture
- 5th Metatarsal fracture
- Mallet Finger Injury
- Paediatric wrist torus (buckle) fracture
- Paediatric clavicle fracture
- Radial head/neck fracture
There is a growing evidence base that the results of routine non-operative treatment of these fractures with symptomatic/functional splintage is successful.
Paediatric Wrist (Torus) Fractures
A prospective RCT demonstrated that the use of backslabs prolonged pain and return to normal function (18277840 ). A minimalist approach to the treatment of these fractures reduced lost school time, and the need for parents to have time off work, along with medical time and expense (15958903). A separate, more recent, RCT confirmed satisfaction and patient/parent preference for splintage versus casting (23603644 ). Similar outcomes have been reported with the use of “Soft-Cast” material, which can be removed at home (23265786 ).
Fifth Metacarpal Fractures
A prospective comparison cohort study compared the outcomes of two different groups – one with regular review and other with discharge with advice and simple neighbour strapping (17125893). The group with early discharge had greater satisfaction if discharged early, and returned to work at an earlier stage. There were similar function outcomes as measured by the DASH score at 12 weeks. Another prospective RCT demonstrated no difference in pain, range of movement, return to work or satisfaction between those treated with immediate mobilisation compared with those immobilised in plaster (14639483 ).
Fifth Metatarsal Fracture
The use of a “boot” was compared with a cast in a prospective RCT in patients with avulsion fractures of the base of fifth metatarsal (14639483 ). The group treated with removable boots had significantly less pain. Function was greated at 3, 6 and 9 weeks. Patients also returned to driving and work at an earlier stage. Functional outcomes were evaulated in a consecutive series of 400 fractures (20714904). The outcome was good and most fractures united. The outcome was dependent on BMI, diabetes, gender and fracture displacement, not location. In another study, treatment in plaster was not associated with a difference in the rate of union (20307430).Similarly, Egol et al found that symptomatic treatment of these fractures in a stiff soled show was associated with return to preinjury status, although this may take up to six months (17559765 ).
Mallet Finger Injury
The type of splint has been shown not to correlate with treatment failure in mallet finger injuries (20353859 ). The main determinant of treatment success is adherence to treatment. A separate study showed no difference in outcome of bony-mallet injuries with or without joint subluxation (15925171 )
Paediatric Clavicle Fracture
The results of paediatric clavicle fractures were universally found to be excellent. One paper has advocated early discharge with no need for further follow-up (12398126 ). A 25 year retrospective study showed no difference in outcome between children treated operatively or non-operatively for distal clavicle fractures (21055749 ).
Radial Head Fractures
The majority of radial head fractures have excellent outcomes (21248649 ). The main determinants were fracture type and comminution. The poor outcomes occured in the Type III and IV fractures which only comprised 8% of the total number. This number is a probably overestimate as there is a tendency for many EDs to refer patients with a painful elbow, no radiological fracture, but a “fat pad sign”. It should be highlighed that ED discharge is appropriate for these patients with isolated radial head fractures and no other evidence of elbow or forearm trauma. The specificty of the “fat pad” sign has been shown to be 50% (9509082 ). A study of repeat radiography in these patients showed that no change in treatment occured on the basis of repeat radiographs, and that therefore further review was unneccessary (1404053 ). Similarly, the long term outcome of displaced Mason I fractures was also favourable (15723016 ).