Virtual Fracture Clinics Match In-Person Care in First Randomized Trial

For more than a decade, hospitals around the world have experimented with a simple idea: instead of asking every patient with a broken bone to travel back to a crowded orthopaedic clinic, why not review them remotely by video or telephone? These so-called virtual fracture clinics, pioneered at Glasgow Royal Infirmary in 2011 and since adopted across England, Australia, Canada, Ireland, India and the Netherlands, have been praised for cutting waiting lists and keeping patients happy. Yet the evidence supporting them has come almost entirely from observational studies, which are vulnerable to bias and often silent on clinical outcomes and adverse events. Now, for the first time, a randomized controlled trial has put the model to a rigorous test, and the results suggest that remote follow-up care for simple fractures is not just convenient but clinically sound.

The trial, known as RECITAL (FRacturE ClinIc TriAL), was conducted at two metropolitan public hospitals in Sydney, Australia, and published in eClinicalMedicine. Its central question was deceptively straightforward: does a physiotherapist-led virtual fracture clinic deliver health outcomes that are no worse than the standard in-person clinic run by orthopaedic surgeons? The stakes are considerable. Globally, there were 178 million new fractures in 2019, a rise of 33.4 percent since 1990, and the annual direct medical cost of fractures in the United States alone is projected to reach US$81.5 billion by 2040. Follow-up care for this flood of injuries strains services everywhere. In the United Kingdom, trauma and orthopaedic outpatient services recorded 7.9 million attendances in 2024-25, while in Australia orthopaedic clinics draw more patients than any other outpatient service, with 1.2 million attendances in 2023-24.

Paradoxically, much of that burden may be avoidable. A systematic review of outpatient fracture services concluded that roughly 48 percent of patients do not need to return to hospital at all, because many simple fractures carry such a clear healing prognosis. Prior cohort studies found that 86 to 100 percent of patients with injuries such as Weber B ankle fractures, Mason I radial head fractures and base-of-fifth-metatarsal fractures achieved bony union by 12 weeks. Simple fractures, as defined in the trial, are those that can be managed without surgery and with short-term immobilisation using a removable orthosis rather than a plaster cast. Against this backdrop, the RECITAL investigators enrolled 312 adults referred to hospital fracture clinics in Sydney between November 2023 and March 2025, randomly allocating them in a 1:1 ratio, with concealed assignment, to either the virtual or the in-person care pathway.

The two pathways reflected existing, routine services rather than bespoke research interventions. Patients in the virtual group received a remote consultation with an experienced physiotherapist within five days of referral, conducted by video conference or telephone. The physiotherapist carried out a remote assessment, explained the injury, and provided tailored advice and exercises aligned with the patient’s own goals, with one or two optional follow-up contacts typically at two and six weeks. Escalation to the in-person pathway was available whenever the physiotherapist judged it necessary. In the comparator arm, patients saw an orthopaedic surgeon face-to-face within seven to ten days of referral for a physical assessment and advice, with similar follow-up arrangements. Patients and clinicians could not be blinded to allocation, but biostatisticians and most of the study team remained blinded until analyses were complete, and the protocol and statistical analysis plan were published in advance.

The primary outcome was physical function at 12 weeks, measured with the Patient-Specific Functional Scale, a validated self-report instrument on which patients rate their ability to perform activities that matter to them, scored from 0 to 10. The trial was designed as a non-inferiority study, meaning the researchers pre-specified a margin of 0.7 points; virtual care would be considered non-inferior provided the lower bound of the 95 percent confidence interval for the between-group difference stayed above minus 0.7 points. This margin was deliberately conservative, roughly half of the smallest change patients typically notice on the scale. With 312 participants, the trial had 90 percent power to detect non-inferiority, assuming a standard deviation of 2.0 points and allowing for 10 percent loss to follow-up.

The results exceeded the investigators’ expectations. At 12 weeks, the mean PSFS score was 9.3 points in the virtual care group versus 8.8 points in the in-person group, an adjusted mean difference of 0.53 points in favour of virtual care (95 percent confidence interval, 0.17 to 0.88; P = 0.004). Not only was the non-inferiority threshold comfortably met, the direction of the difference actually favoured the remote pathway, although the investigators caution that a benefit of this size falls below the threshold usually considered clinically important. At week 6 the gap was wider still, with a mean difference of 0.82 points. Pain scores told a similar story: at six weeks, virtual care patients reported significantly less pain (mean difference, minus 0.8 points) and were less likely to be taking pain-relieving medication, 8 percent versus 14 percent, while by 12 weeks pain and health-related quality of life, measured with the EQ-5D-5L, were statistically indistinguishable between the groups.

Safety signals, a weak spot in the earlier literature, were reassuring. Adverse events were captured through participant surveys at six and 12 weeks and supplemented by a systematic review of hospital electronic medical records. Nineteen participants, 12 percent, in the virtual group experienced at least one adverse event, compared with 34 participants, 22 percent, in the in-person group, with the excess in the latter driven largely by reports of high pain or swelling. Unplanned fracture-related surgery occurred in one virtual care participant, 1 percent, and four in-person participants, 2 percent. Most of the serious adverse events recorded in both arms were hospital re-presentations unrelated to the fracture, such as gastrointestinal or respiratory problems. Healthcare utilisation also differed markedly: only 18 percent of virtual care patients had follow-up radiology scans compared with 40 percent of in-person patients, and fewer virtual patients sought additional care from other health professionals.

Adherence to the allocated pathways was strikingly high, with 96 percent of participants receiving care as assigned. Virtual care patients attended a mean of 3.4 follow-up appointments, more than the 1.5 attended by the in-person group, yet they still avoided the hospital entirely for most contacts. Only 12 participants in the virtual arm crossed over to in-person care, 11 of them referred by their treating physiotherapist for escalation, a recall rate of about 7 percent that compares favourably with the average recall rate of 42.4 percent reported for virtual clinics in systematic reviews. The trial also captured an intriguing sociological detail: among patients who declined randomisation because of a strong treatment preference, more favoured the virtual pathway, 154, than the in-person clinic, 94, hinting at growing public appetite for remote care.

The investigators acknowledge limitations. Participants could not be blinded, creating potential for performance bias, although they were unaware of the study hypothesis and reported outcomes directly through a web-based system. Radiological healing was not assessed, reflecting standard practice for simple fractures and growing evidence that routine follow-up imaging adds little clinical value. The sample size precluded subgroup analyses by fracture type, and the findings cannot yet be generalised to children or to complex injuries requiring surgery or casting. The authors also note that the greater number of follow-up contacts in the virtual arm may have contributed to better outcomes through reassurance and earlier detection of problems, a mechanism that warrants further study alongside a formal cost-effectiveness evaluation, which is planned separately.

Even with those caveats, RECITAL marks a turning point for virtual fracture care. By providing the first randomized evidence that a physiotherapist-led remote pathway is non-inferior to surgeon-led in-person care on patient-important function, while suggesting equivalent or better safety and patient experience, the trial lends rigorous support to what observational studies have long hinted at. If health systems adopt the model at scale, specialists could be freed to focus on complex injuries, and patients in rural and remote areas could avoid long journeys for appointments they may not need. With fractures rising steadily worldwide and orthopaedic waiting rooms overflowing, the humble video call may prove one of the simplest tools available to keep broken bones, and broken health systems, from costing more than they should.

Subject of Research: Virtual fracture clinic pathway versus in-person care for simple fractures

Article Title: ‘Virtual’ fracture clinic pathway for patients with simple fractures (RECITAL): a non-inferiority, randomised controlled trial

Article References: Teng, M. J., Zadro, J. R., Copp, T., Pickles, K., Khoudair, I., Warnock, B., Shaw, M., Hutchings, O., Horsley, M., Petchell, J., Liu, X., Llewellyn, S., Ackerman, I. N., Thomas, R., Charteris, R., Maher, C. G., & Traeger, A. C. (2026). ‘Virtual’ fracture clinic pathway for patients with simple fractures (RECITAL): a non-inferiority, randomised controlled trial. eClinicalMedicine, Article 104198. https://doi.org/10.1016/j.eclinm.2026.104198

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104198

Keywords: virtual fracture clinic, telemedicine, simple fractures, non-inferiority trial, randomized controlled trial, physiotherapist-led care, orthopaedics, patient outcomes, remote healthcare, fracture follow-up, Virtual, fracture