System-Level Barriers to National Institute for Health and Care Excellence (NICE) Guideline Compliance in Distal Radius Fracture Management: A Retrospective Audit Study

Background Distal radius fractures are among the most common orthopaedic injuries, particularly in the elderly population. The UK's National Institute for Health and Care Excellence (NICE) provides clear management guidelines, yet adherence remains inconsistent. This quality improvement project evaluated and enhanced compliance with NICE standards for the management of dorsally angulated distal radius fractures at University Hospitals Birmingham NHS Foundation Trust, a major trauma centre in Birmingham, United Kingdom. Methods A two-cycle audit was undertaken using the Plan-Do-Study-Act (PDSA) framework. Cycle 1 (May-August 2020) retrospectively reviewed 30 adults to assess compliance with NICE recommendations for manipulation. Following an educational intervention, Cycle 2 (June-August 2023) evaluated 43 adults requiring surgery, focusing on compliance with NICE surgical timing standards. Data were obtained from electronic patient records. Results In Cycle 1, 90% (27/30) of patients received manipulation in the emergency department (ED), indicating good baseline compliance. In Cycle 2, only 11.6% (5/43) underwent surgery within the NICE-recommended timeframe - 10% (4/40) for intra-articular fractures (target ≤ 72 hours) and 33.3% (1/3) for extra-articular fractures (target ≤ 7 days). The mean time to surgery was 8.6 days for intra-articular and 6.3 days for extra-articular fractures. Limited theatre capacity accounted for 73.7% (28/38) of delays. Conclusions Educational measures improved awareness but did not resolve system-level barriers. Theatre capacity and list allocation remain the main obstacles to timely surgical management. Achieving full compliance with NICE guidance requires combining educational reinforcement with structural and resource-based solutions.