Optimising Management of Paediatric Distal Radius Torus Fractures: A Complete Two-Cycle Audit Assessing Compliance With National Institute for Health and Care Excellence (NICE) Guideline NG38

Background: Distal radius torus (buckle) fractures are among the most common paediatric injuries presenting to emergency departments. National Institute for Health and Care Excellence (NICE) guideline NG38 recommends management with non-rigid immobilisation and discharge without routine follow-up. Despite robust evidence supporting this approach, clinical practice varies considerably across NHS settings. Aim: This study aims to assess baseline compliance with NICE NG38 in the management of paediatric distal radius torus fractures, implement targeted quality-improvement interventions, and evaluate their effect through a complete closed-loop audit cycle. Methods: A retrospective two-cycle clinical audit was conducted at a District General Hospital (DGH) and its associated Minor Injury Unit (MIU) within the same NHS trust in the United Kingdom. Cycle 1 (February 2023 to August 2023, n = 222) established baseline practice. Interventions included clinician education, guideline dissemination, and visual prompts. Cycle 2 (March 2024 to September 2024, n = 258) evaluated post-intervention practice. Data were collected from electronic emergency department records, radiographic systems, and Virtual Fracture Clinic (VFC) documentation. Results: In Cycle 1, compliance with NICE NG38 was 97/174 (56%) at the DGH and 0/48 (0%) at the MIU; 128/222 (58%) of all patients across both sites received unnecessary fracture clinic follow-up. Following interventions, Cycle 2 demonstrated improved compliance to 131/164 (80%) at the DGH and 29/94 (31%) at the MIU. Overall fracture clinic follow-up was reduced from 128/222 (58%) to 98/258 (38%). Rigid immobilisation persisted in 33/164 (20%) of DGH patients and 65/94 (69%) of MIU patients in Cycle 2. Conclusion: This closed-loop audit demonstrates that targeted educational and environmental interventions can meaningfully improve adherence to evidence-based guidelines and reduce unnecessary fracture clinic referrals. However, variability in immobilisation practice persists, particularly at the MIU, underscoring the need for sustained system-level interventions, standardised clinical pathways, and ongoing audit cycles.