Title : Adherence to boast guidelines on early management of the paediatric forearm fracture – lessons to learn for a digital future
Abstract:
Introduction: An audit was undertaken at East Suffolk and North Essex NHS Foundation Trust, Ipswich Hospital, with the aim of identifying where there were deficiencies in implementation of British Orthopaedic Association Standards (BOASt) guidelines on the early management of paediatric forearm fractures. A further aim was to harness the advent of our new Electronic Patient Record (EPR) ‘Epic’ to highlight potential pitfalls, strengths, and novel solutions that could be generalised for application to other centres, as there is a growing trend to move away from paper-based and disparate record systems to unified EPRs. Possible avenues for multi-centre collaboration are highlighted.
Methods: Data was collected retrospectively using Epic EPR. The inclusion and exclusion criteria were taken from the BOASt guidelines.
Inclusion Criteria: “Skeletally immature patients seen in Emergency Departments following angulated (but not off-ended) forearm fracture”
Exclusion Criteria: “Fractures that following interdisciplinary discussion require management in the operating theatre due to either patient or injury related factors” The search returned all relevant patient presentations between 02/10/2025 and 25/03/2026.
Results: A total of 138 patient records were returned by the search and reviewed, of which 8 met inclusion criteria for further analysis. This is in-keeping with the sample size from the previous audit on this topic at Ipswich Hospital. A number of key areas for improvement were identified:
•There was a tendency for neurovascular status pre- and post- manipulation to be documented simply as ‘NVI’, meaning neurovascularly intact, rather than specifically detailing the status of the radial pulse, digital capillary refill time, and the individual functions of the radial, median, and ulnar nerves. Complete documentation was only achieved 50% of the time prior to manipulation and 25% afterwards.
•Documentation of pain scores was inconsistent, only occurring in 13% of cases.
•Formal consent was only documented in 50% of cases.
•Provision of TTO analgesia and leaflets was not documented.
Overall adherence was greater when assessment and management was undertaken by specialists in trauma and orthopaedics. Adherence was otherwise 100%.
Conclusions: These results highlight two overarching issues. The first is that paediatric forearm fractures severe enough to require manipulation i.e., not the commonly observed torus fractures, but not so severe as to require theatre, are uncommon. This creates challenges in obtaining large sample sizes, especially across a recent enough timeframe to maintain relevance. This could be overcome through multicentre data sharing that will be augmented by emerging digital unified EPRs, such as Epic. The above points may also be comprehensively addressed through creation of an automatically generated interactive digital proforma encompassing assessment, consent, treatment, and discharge planning, via the ‘smart text’ function in Epic. This could be supplemented with teaching for residents and allied healthcare professionals in the emergency department. Re-audit will be done in 4 months. Multi-centre collaboration could be considered based on the results.
