Virtual fracture clinics for stable musculoskeletal injuries: a systematic review of safety, reattendance and cost-effectiveness (2014–2025)

Purpose To synthesise evidence (1 Jan 2014–11 Nov 2025) on Virtual Fracture Clinics (VFCs) for stable musculoskeletal injuries, focusing on (1) safety (missed/delayed diagnosis, unplanned operation, major complications), (2) unplanned reattendance (ED/clinic), and (3) direct health-service costs per patient. Overview This is a structured narrative review with an optional meta-analysis where ≥3 sufficiently homogeneous studies report compatible measures. We will search Ovid MEDLINE, Embase, CINAHL, Web of Science Core Collection, EconLit, trial registries (ClinicalTrials.gov, ISRCTN), and grey literature (NIHR Journals Library, NHS Knowledge & Library Hub, local NHS service evaluation reports, relevant conference abstracts, targeted Google Scholar). Human studies in English only. Eligibility Adults and/or children with “stable” injuries as defined by each study and suitable for non-operative outpatient management within VFC pathways. Interventions include consultant/ANP-led asynchronous or telephone/video triage/review. Comparators may include face-to-face clinics or historical (pre-VFC) cohorts. Outcomes must include ≥1 of: safety, unplanned reattendance, or direct costs. Tele-rehabilitation programmes without a VFC triage component are excluded unless VFC outcomes are separable. Methods (brief) Screening and extraction in Rayyan with a documented audit trail; 10% double-screen/verify if feasible. Risk of bias: ROB 2 (RCTs), ROBINS-I (non-randomised comparative), JBI (case series/cross-sectional/service evaluations), CHEC for economic evaluations, with CHEERS 2022 for reporting completeness. Primary synthesis is narrative (direction/consistency/quality). For sparse binary outcomes we will use a binomial-normal GLMM random-effects model (sensitivities include Mantel–Haenszel/Peto as appropriate). Costs will be standardised to 2025 GBP via within-country inflation then PPP (CCEMG–EPPI approach). Reporting will follow PRISMA 2020 (flow) and SANRA (narrative quality). We will not make formal non-inferiority claims; we will compare absolute/relative risks with 95% CIs and flag clinically notable absolute differences (≥1%) as signals for caution.