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Introduction: Chronic pain affects up to 40% of patients at 7 years after tibial fracture impacting on their quality of life (QoL) and ability to participate in activities of daily living. Major nerves run in close proximity to the tibia and are prone to injury during tibial fracture. Nerve injury can cause acute neuropathic pain, which responds poorly to commonly prescribed analgesics and predisposes patients to developing chronic pain. This study aims to describe the incidence and impact of pain at 6-12 months after tibial fractures. Methods: Patients admitted to a major trauma centre between 01/01/2016 – 31/12/2016 with isolated tibial fractures were identified using prospectively recorded database eTrauma. Injuries were categorized using the AO classification. Pain and Quality of Life at 6-12 months post injury were assessed using the EuroQol (EQ-5D-5L) questionnaire and the Douleur Neuropathique 4 questionnaire for neuropathic pain. Results: Forty isolated tibial fractures were identified and 20 were followed up. Pain was reported by 18 (90%) of patients. Ten (50%) reported moderate to severe pain, with median pain scores of 2.6/5. Pain scores were significantly greater following high-energy injuries however no significant links were seen between pain and other patient, injury or management factors. Conclusion: Chronic pain is common following tibial fracture and is largely under-reported. Further prospective multi-center investigation is warranted to better identify those with neuropathic pain and other risk factors for chronic pain. This could guide effective management and improve patient outcomes

We describe a clinician-led transformation of trauma and orthopaedics services in one of the country’s largest integrated healthcare trusts. Analysis of 2638 outpatient surgical procedures showed an unacceptable delay (mean=16.1 days) from injury to surgical treatment. A 5 year retrospective review of trust litigation cases yielded 28 litigation cases related to failure/delay of treatment or diagnosis for traumatic injuries with resultant total claims of £2,000,000. A novel N3-network hosted cloud-based bespoke single-point referral management system was developed. Referrals are processed at a specialist-led Virtual Fracture Clinic (VFC) with patients allocated to specific digitally actioned treatment pathways. Key stakeholders including referrers, assessors and treatment providers were involved from the early stages of system design. Regular on-platform feedback is obtained for quality control and iterative improvements. 11 769 patients have been assessed in VFC since March 2017. Post-implementation, 720 outpatient surgical procedures were performed with a significant reduction in mean time from injury to treatment (9.6 days). The British Orthopaedic Association target of 67% of assessors felt that VFC reduces F2F appointments and is overall beneficial. 90% of patients that were discharged without a F2F appointment were positive or neutral about the service. 77% of referrers felt the system was safer for patients and 71% felt that it was an overall improvement. Cost analysis showed a £1 04 576 cost saving in addition to perceived further litigation-related savings. Frictionless digital referral management and virtual clinical pathways can improve patient care and help manage increasing workload pressures whilst simultaneously reducing costs and maintaining stakeholder satisfaction.