Excerpt

Two of the five guidelines in the NICE Trauma Suite relate to fractures. These are titled non-complex and complex fractures. In broad terms the non-complex fractures are those likely to be treated at the receiving hospital, whereas the complex fractures require transfer or the consideration of transfer of the injured person to a specialist centre.

There are no agreed definitions for complex fractures and so estimating their true incidence is difficult. Complex fractures are considered to make up the minority of the estimated 1.8 million fractures occurring in England each year, they are associated with considerable morbidity and are a large burden on healthcare resources. The treatment of complex fractures usually requires interaction between multiple healthcare professionals and specialists and the patient pathway is often complex.

A single guideline covering all aspects of complex fractures is not possible to achieve. Therefore, a unique approach had to be utilised to develop a guideline that would be of benefit to patients, clinicians and healthcare providers in the treatment of complex fractures.

Instead of tracing the pathway of a single type of complex fracture, the guideline uses three injuries to inform various stages on the pathway of patient care. The themes of open fracture, pelvic fracture and pilon fracture were chosen on the basis of their general applicability. The individual topics for each were chosen on the basis of their relevance to particular steps in the patient pathway of care, a perceived variation in current practice or their individual clinical importance. Consequently, the guidelines are not comprehensive for any individual injury. However, it was inherent in the development of the guideline that whilst recommendations are necessarily made only in relation to the individual topics of the scope, these recommendations should where possible be considered as representative of the management of complex fractures in general.

High-energy pelvic fractures may in themselves present a significant mechanical challenge in orthopaedic trauma. However, it is their potential to be associated with life-threatening haemorrhage or other significant injuries that sets them apart. High-energy pelvic fractures are, therefore, used to explore aspects of pre-hospital care, triage, transfer and emergency treatment.

Whilst open fractures may be associated with other serious injuries, it is the combination of a fracture, significant soft issue involvement and the propensity for infection that are pre-eminent with these injuries. There are some particular technical issues in the care of open fractures that are addressed, but much is directed at assessing the required expertise and timing of treatment.

Whilst the practice has evolved where high-energy pelvic fractures and open fractures tend to be transferred to a specialist centre for care at some stage in their management, this is often not the case with pilon fractures. Pilon fractures are injuries of the weight-bearing joint surface of the lower tibia, they are often difficult to manage, complications rates are often high and the outcome of treatment tends to be poor. In addition to the specific issues in their management, they can be used as an example to explore the desirability of concentrating patients or expertise for difficult, less common injuries

In summary, there are particular technical issues addressed for each of the complex fractures considered, but additionally, there are recurring questions across the types relating to the necessary availability of expertise, the urgency of delivering care and logistic consequences of these requirements.

Contents

• Guideline Development Group full members
• Guideline Development Group expert members
• Project Executive Team members
• NCGC technical team members
• Acknowledgements
• 1. Foreword
• 2. Introduction
• 3. Development of the guideline
  • 3.1. What is a NICE clinical guideline?
  • 3.2. Remit
  • 3.3. Who developed the trauma guidelines?
• 4. Methods
  • 4.1. Developing the review questions and outcomes
  • 4.2. Searching for evidence
  • 4.3. Evidence gathering and analysis
  • 4.4. Evidence of cost-effectiveness
  • 4.5. Developing recommendations
• 5. Guideline summary
  • 5.1. Full list of recommendations
  • 5.2. Key research recommendations
• 6. Open fractures
  • 6.1. Immediate destination of people with open fractures
  • 6.2. Limb salvage
  • 6.3. Antibiotics
  • 6.4. Dressings before debridement
  • 6.5. Arterial shunts
  • 6.6. Orthoplastic approaches for open fractures
  • 6.7. Optimal timing of debridement
  • 6.8. Staging of fixation and cover
  • 6.9. Timing of cover
  • 6.10. Definitive dressings after debridement
• 7. Pelvic fractures
  • 7.1. Initial destination for people with pelvic fractures
  • 7.2. Timing of transfer for patients with pelvic fractures
  • 7.3. Decision for pelvic binders
  • 7.4. Pelvic binder duration
  • 7.5. Timing of log roll
  • 7.6. Pelvic imaging
  • 7.7. Pelvic cystourethrogram
  • 7.8. Pelvic haemorrhage control
• 8. Pilon fractures in adults and intra-articular distal tibia fractures in children
  • 8.1. Pilon transfer
  • 8.2. Staging of pilon fixation
  • 8.3. Type of pilon fixation
• 9. Other
  • 9.1. Identifying vascular compromise
  • 9.2. Detecting compartment syndrome
  • 9.3. Splinting of lower limb long bone fractures
  • 9.4. Hip reduction
  • 9.5. Whole-body CT
  • 9.6. Documentation of open fracture wound photographs
  • 9.7. Documentation of neurovascular compromise
  • 9.8. Information and support
• 10. Access to the skills required for the management of people with complex fractures
  • 10.1. Introduction
• 11. Acronyms and abbreviations
• 12. Glossary
• References
• Appendices A - F
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Review protocols
  • Appendix D. Clinical article selection
  • Appendix E. Economic article selection
  • Appendix F. Literature search strategies
  • References
• Appendices G - H
  • Appendix G. Clinical evidence tables
  • Appendix H. GRADE tables
  • References
• Appendices I - P
  • Appendix I. Forest plots
  • Appendix J. Excluded clinical studies
  • Appendix K. Excluded economic studies
  • Appendix L. Cost analysis for open fractures
  • Appendix M. Research recommendations
  • Appendix N. NICE technical team
  • Appendix O. Additional cost data
  • Appendix P. Qualitative study checklist
  • References

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.