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The Heidari Publications
94 publications · 23 years of research · click or drag a page corner to turn
Royal College
British Orthopaedic
AO Trauma
Churchill
Limb Recon
Specialist Reg.
Zahan N, Patel A, Atkinson K, Jha S, Heidari N, Parker L, Vris A, Malagelada F, Jeyaseelan LA.
Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Overwhelming demand for trauma services with increasing emergency department (ED) attendances, has increased pressure on fracture clinics in many units, with this demand exceeding capacity. Virtual fracture clinics (VFCs) have been shown to be safe and cost-effective in many specialties. Optimal treatment of 5th metatarsal base fractures remains controversial. Complications of base of 5th metatarsal fractures include delayed union and painful mal/non-union. Surgical fixation has been shown to enable faster return to sport, with lower faster union times and lower non-union rates than conservative management. The aims of this study were to assess whether the management of 5th metatarsal base fractures using a VFC model is safe, cost-effective and accceptable to the patients, whilst avoiding undesirable outcomes. Methods: All patients presenting to the VFC at our major trauma centre, with a 5th metatarsal base fracture between January 2019 and December 2019 were included in the study. One hundred and thirty six patients were identified. All patients had a standardised VFC treatment protocol including full weight bearing in a walker boot, rehabilitation planning to wean out of the boot and advice to contact the unit for follow-up if ongoing pain after 4 months. Minimum follow-up was one year. Patient records were retrospectively reviewed for baseline demographic data, including co-morbidities and smoking history. Overall complication rates, including mal and non-union as well as operative intervention rates were noted. Patients from the cohort who required face to face appointments were identified and the cause for return was identified. A cost analysis was also performed to evaluate the financial implications of the service. Results: Mean age was 41,6 years (18-92). Average time from ED attendance to VFC review was 2 days (1 - 5). Fractures were classified according to the Torg Classification with 106 (78%) Type 1 fractures, 15 (11%) Type 2 fractures and 15 (11%) Type 3 fractures. At VFC, 135/136 (99.2%) were discharged with the appropriate 5th metatarsal base fracture protocol. Twelve patients (8.8%) arranged further follow-up after initial discharge. The most common reason for return was ongoing pain (6/8 - 75.0%). This subgroup of the patients required an average of 3 (1-6) further appointments. There was 1 non-union during the study period. Based on 2 face to face visits on a traditional pathway, 248 clinic visits were saved with an approximate cost saving of nearly £40,000 ($55,500). Conclusion: Our study supports the management of 5th metatarsal base fractures in the VFC setting. We have shown that the VFC model, with well a defined protocol is both safe and cost effective. Fifth metatarsal base fractures have good outcomes with conservative management, removing the traditional need to have in-person clinic visits to confirm the diagnosis, management and prognosis.
What did we look at?
Whether broken bases of fifth-metatarsal bones (a common foot fracture, usually after a twist or stumble) can be safely managed without an in-person fracture clinic visit at all — using a “virtual fracture clinic” model where the diagnosis and treatment plan are confirmed remotely from the emergency-department images. We followed 136 patients for a minimum of one year.
Why did we look at it?
Hospital fracture clinics are overstretched, and most fifth-metatarsal base fractures heal well with a walker boot and planned weaning. Bringing every such patient back for an in-person clinic visit consumes time and money without obviously changing the outcome. The trade-off is that virtual review must not miss the small number of patients who genuinely need surgery or closer follow-up.
What did we find?
Following a standardised protocol — weight-bearing in a boot, weaning, and an open invitation to come back if pain persists past four months — 99% of patients were safely discharged at the virtual stage. Only 9% subsequently needed a face-to-face visit, mostly for ongoing pain. There was one non-union in the entire group. Compared with a traditional two-visit pathway, the virtual model saved approximately 248 clinic appointments and around £40,000.
What does this mean for patients?
For most patients with a typical fifth-metatarsal base fracture, a virtual fracture clinic with a clear protocol is a safe and convenient alternative to attending the hospital in person — with a clear safety net for patients whose pain doesn’t settle. The model was also financially beneficial to the NHS, freeing clinic capacity for patients with more complex injuries.
Foot & Ankle Orthopaedics 2022. doi:10.1177/2473011421s00513