The delayed presentation of limb fractures in A&E departments.

The delayed presentation of limb fractures in A&E departments Sir, There appears to be a difference of opinion among accident and emergency specialists as to whether patients with injuries over 48 h old should be regarded as inappropriate attenders or otherwise. Varying viewpoints may be reflected in the content of waiting room poster displays, departmental handouts, and in the advice given to patients by triage nurses and nurse practitioners. A prospective study was carried out in the accident and emergency department in Walsall over a 6 month period (1 October, 1989 to 1 March, 1990) to ascertain the extent to which delayed reporting of symptoms occurs with limb fractures and its effect on departmental workload. During the period of study, 24147 patients were seen in the department as first-time attenders. In the same period, 1867 patients were referred from the department to five weekly fracture and soft tissue injury clinics. A further 540 patients attended with limb injury sustained 48 h or over prior to initial attendance on self-suspicion of fracture. Of these 540 320 patients were thought to require X-rays on clinical grounds. A total of 117 were found to have fractures on X-ray examination. The fractures diagnosed are enumerated in Table 1 and the treatments required are enumerated in Table 2. The following reasons for delayed attendance were identified from the records: (1) Own remedies tried initially (28); (2) Difficulty in getting to hospital at the time of injury (20); (3) Self-exclusion of fracture and underestimation of injury severity (16); (4) Seen by another doctor who excluded a fracture clinically (11); (5) Away on holiday at time of injury (9); (6) Under influence of alcohol at time of injury (4); (7) In children, when the injury was not brought to the parents' attention (4); (8) Mentally handicapped with difficulty in assessment (3); (9) Non-accidental injury (1) and; (10) Inadequate documentation with unknown reason for delayed attendance (21). The delayed reporting of symptoms due to limb fractures appears not to have been discussed in the literature previously. However, fractures may have subtle presentations or may be of insidious onset. Also, stoical individuals may deliberately delay seeking medical attention While it is true that many of these late diagnosed fractures may either need symptomatic or no treatment, the identification of a fracture can allow clear prognostic information based on the anticipated healing time of the fracture diagnosed. 220