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Fractures (Non-Complex): Assessment and Management Fractures: Diagnosis, Management and Follow-Up of Fractures

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Fractures (Non-Complex): Assessment and Management Fractures: Diagnosis, Management and Follow-Up of Fractures National Clinical Guideline Centre 1 DRAFT FOR CONSULTATION Fractures (non-complex): assessment and management Fractures: diagnosis, management and follow-up of fractures Clinical guideline <...> Methods, evidence and recommendations August 2015 Draft for consultation Commissioned by the National Institute for Health and Care Excellence Fractures: non complex Contents 1 Disclaimer Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and, where appropriate, their guardian or carer. Copyright National Clinical Guideline Centre, 2015 Funding National Institute for Health and Care Excellence National Clinical Guideline Centre, 2015 Fractures: non complex Contents Contents Guideline Development Group full members ............................................................................... 11 Guideline Development Group expert members .......................................................................... 11 Project Executive Team members ................................................................................................. 11 NCGC technical team members .................................................................................................... 12 Peer reviewers ............................................................................................................................... 13 Acknowledgements .................................................................................................................... 14 1 Foreword ............................................................................................................................. 15 2 Introduction ........................................................................................................................ 16 3 Development of the guideline .............................................................................................. 17 3.1 What is a NICE clinical guideline? ....................................................................................... 17 3.2 Remit ................................................................................................................................... 17 3.3 Who developed the trauma guidelines? ............................................................................. 18 3.3.1 What this guideline covers ..................................................................................... 18 3.3.2 What this guideline does not cover ....................................................................... 19 3.3.3 Relationships between the guideline and other NICE guidance ............................ 19 4 Methods .............................................................................................................................. 20 4.1 Developing the review questions and outcomes ................................................................ 20 4.2 Searching for evidence ........................................................................................................ 28 4.2.1 Clinical literature search ......................................................................................... 28 4.2.2 Health economic literature search ......................................................................... 28 4.3 Evidence gathering and analysis ......................................................................................... 29 4.3.1 Inclusion and exclusion criteria .............................................................................. 29 4.3.2 Type of studies ....................................................................................................... 30 4.3.4 Methods of combining evidence ............................................................................ 30 4.3.5 Appraising the quality of evidence by outcomes ................................................... 34 4.3.6 Assessing clinical importance ................................................................................. 41 4.3.7 Clinical evidence statements .................................................................................. 41 4.4 Evidence of cost-effectiveness ............................................................................................ 41 4.4.1 Literature review .................................................................................................... 41 4.4.2 Undertaking new health economic analysis .......................................................... 43 4.4.3 Cost-effectiveness criteria ...................................................................................... 44 4.5 Developing recommendations ............................................................................................ 44 4.5.1 Research recommendations .................................................................................. 45 4.5.2 Validation process .................................................................................................. 45 4.5.3 Updating the guideline ........................................................................................... 45 4.5.4 Disclaimer ............................................................................................................... 45 National Clinical Guideline Centre, 2015 4 Fractures: non complex Contents 4.5.5 Funding ................................................................................................................... 45 5 Guideline summary .............................................................................................................. 46 5.1.1 Full list of recommendations .................................................................................. 46 5.2 Key research recommendations ......................................................................................... 50 6 Initial pain management and immobilisation ........................................................................ 51 6.1 Initial pharmacological pain management.......................................................................... 51 6.1.1 Introduction ........................................................................................................... 51 6.1.2 Review question: What is the most effective initial acute pharmacological management to alleviate pain in patients with a suspected long bone fracture (tibia and fibula, humerus, radius and ulna, or unspecified) in acute care settings? ................................................................................................................. 51 6.1.3 Clinical evidence ..................................................................................................... 52 6.1.4 Economic evidence ................................................................................................. 62 6.1.5 Evidence statements .............................................................................................. 63 6.1.6 Recommendations and link to evidence ................................................................ 66 6.2 Paediatric nerve blocks femoral fractures .......................................................................... 71 6.2.1 Introduction ........................................................................................................... 71 6.2.2 Review question: What is the most clinically and cost-effective nerve block for the initial management in patients with a suspected femoral fracture in acute care settings (pre-hospital and ED)? ............................................................ 71 6.2.3 Clinical evidence ..................................................................................................... 72 6.2.4 Economic evidence ................................................................................................. 74 6.2.5 Evidence statements .............................................................................................. 75 6.2.6 Recommendations and link to evidence ................................................................ 75 7 Acute stage assessment and diagnostic imaging ................................................................... 78 7.1 Selecting patient for imaging – clinical prediction rules for knee fractures ....................... 78 7.1.1 Introduction ........................................................................................................... 78 7.1.2 Review questions ................................................................................................... 78 a) Are validated clinical prediction rules clinically and cost effective at predicting suspected knee fractures? ..................................................................................... 78 b) Are validated clinical prediction rules accurate at predicting suspected knee fractures? ............................................................................................................... 78 7.1.3 Clinical evidence ..................................................................................................... 79 7.1.4 Diagnostic accuracy findings .................................................................................. 84 7.1.5 Economic evidence ................................................................................................. 89 7.1.6 Evidence statements .............................................................................................
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