Objectives & Background Elbow injuries associated with fat pads on X-ray are traditionally treated as fractures. Studies show fracture rates vary from 23%¹ to 90.2%² with follow up imaging. In 2006 Sheffield Children's Hospital (SCH) Emergency Department (ED) created a guideline advising isolated fat pad injuries do not need automatic referral to fracture clinic. Review is in ED Clinic at 7 days, unless x-ray is reported as a fracture. If concerns persist referral to fracture clinic should occur. This service evaluation assesses if the guideline is being followed, its safety, cost effectiveness and variation in diagnosis and management between professionals.

Methods We retrospectively reviewed all elbow X-rays, with their ED and radiological reports, taken in the ED at SCH from June 2014 to May 2015. Those with an initial interpretation of fat pad only by the ED clinician were included. ED and hospital notes were reviewed for management and diagnoses.

Results 99 isolated fat pad injuries were identified– 5 discharged immediately. 64 were referred to ED clinic as per protocol and 30 referred directly to fracture clinic. Radiology identified 11/94 as fractures of which 4 had ED clinic follow up. 3/4 were flagged by radiology, 2 were redirected to fracture clinic. 1 went from ED clinic to fracture clinic; diagnosed as a soft tissue injury (STI). 1 was not flagged and reattended with a diagnosis of STI.

Of the remaining 62, 43 attended. 7 were referred to fracture clinic. 2/7 were diagnosed as fractures.

Of the 30 referred to fracture clinic directly, 7 had a fracture reported by radiology. 5/7 were diagnosed as a fracture. Of those reported as no fracture, 5 fractures were diagnosed clinically. 33% of all fracture clinic reviews were diagnosed as fractures compared to 1.6% of all those seen in ED clinic.

Radiologists and Orthopods agreed in 71% of fractures.

There were 5 unplanned re-attenders; 1(originally referred to fracture clinic directly) was diagnosed as a fracture.

Taking into account clinic costs alone a saving of £9,965 was estimated in this population of 94 patients.

Conclusion Our evaluation shows it is both safe and cost effective to treat simple, fat pad positive elbow injuries with collar and cuff and ED review at 7 days. There are significant cost benefits and with an appropriate safety net and radiology reporting system, no fractures requiring significant intervention were missed.