Post-Splinting Radiographs of Minimally Displaced Fractures: Good Medicine or Medicolegal Protection?

Chaudhry, Sonia; DelSole, Edward M.; Egol, Kenneth A.

doi:10.2106/jbjs.k.00944

Cited by 26 publications

(30 citation statements)

References 10 publications

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“…It is questionable whether routine imaging following the initial follow-up (that is, after 2 weeks), after which definitive treatment is established (being surgical or conservative), is justified [8]. Three retrospective studies have suggested that radiographs performed beyond the 2-week follow-up result in longer waiting room visits, unnecessary radiation exposure and increased healthcare costs without providing additional clinical information which impacts clinical decision-making [8-10]. Alongside the clinical question about the justification of the radiographs after the initial follow-up period, a cost-effectiveness analysis is indicated as the current protocols appear not to be cost effective.…”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…However, it is questionable whether routine imaging following the initial follow-up (that is, post 2-weeks) is justified [8]. Justification for obtaining radiographs beyond the initial follow-up includes documentation of splint application, resident education, assurance that the fracture has not displaced, and medico-legal protection against claims of unintended harm [8]. Three retrospective studies have suggested that routine radiography performed beyond the 2-week follow-up results in longer waiting room visits, unnecessary radiation exposure and increased healthcare costs without providing additional clinical information that impacts clinical decision-making [8-10].…”

Section: Introductionmentioning

confidence: 99%

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WARRIOR-trial - is routine radiography following the 2-week initial follow-up in trauma patients with wrist and ankle fractures necessary: study protocol for a randomized controlled trial

Weil

Termaat

Rubinstein³

et al. 2015

Trials

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BackgroundExtremity fractures such as wrist and ankle fractures are a common and costly healthcare problem. The management of these fractures depends on fracture type and loss of congruity of the joint, resulting in cast immobilization or operative treatment. Loss of congruity or displacement leading to uneven joint loading, osteoarthritis and an increased probability of a poor functional outcome should be identified within the first 2 weeks post-trauma, based upon radiographs to determine optimal treatment. After this period, routine radiographs are scheduled for monitoring the bone-healing process. Current protocols describe imaging at 1, 2, 6 and 12 weeks post-trauma. However, it is questionable whether routine radiography following the initial follow-up ( 2-weeks post-trauma) is cost effective.The aim of this study is to determine whether a modification of the radiographic follow-up protocol can be conducted with no worse outcome and less cost than the current standard of care for patients with a wrist or ankle fracture.Methods/designIn a multicenter randomized controlled trial, 697 patients aged 18 years or older will be included: 385 wrist fracture- and 312 ankle fracture patients. Patients will be randomized into two groups: Group 1 receives usual care, consisting of radiographs 1, 2, 6 and 12 weeks post-trauma; Group 2 receives radiographs beyond the initial follow-up only when clinically indicated. The primary outcome is the overall extremity-specific function. For wrist fractures, this includes the Disabilities of the Arm, Shoulder and Hand Score; for the ankle fractures, this includes the Olerud and Molander ankle score. Secondary outcomes include: healthcare cost, the specific function measured with the Patient Rated Wrist and Hand Evaluation for wrist fractures and American Academy of Orthopaedic Surgeons foot and ankle questionnaire for ankle fractures, pain-intensity, health-related quality of life, self-perceived recovery, and complications. Both groups will be monitored at 1, 2, and 6 weeks and 3, 6, and 12 months.DiscussionThis study will provide data on (cost) effectiveness of routine radiography in the follow-up of wrist and ankle fractures, and could pave the way for a change in (inter)national protocols.Trial registrationNetherlands Trial Register NTR4610, registration date 22 June 2014.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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WARRIOR-trial - is routine radiography following the 2-week initial follow-up in trauma patients with wrist and ankle fractures necessary: study protocol for a randomized controlled trial

Weil

Termaat

Rubinstein³

et al. 2015

Trials

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“…2,3 Although our study did not ask respondents about their practices regarding postsplinting radiographs of minimally displaced fractures, it is worthwhile to note that there has been some recent investigation into this topic. Chaudhry et al 7 found that post-splinting radiographs of nondisplaced/minimally displaced fractures that do not undergo manipulation during or before immobilization do not have clinical utility but do increase costs, wait times, and radiation exposure. They concluded that post-splinting radiographs in these cases could be for-gone.…”

Section: Percent Of Postoperative Visits For Asymptomatic Patients Wimentioning

confidence: 99%

“…Similarly, Chaudhry et al studied post-splinting radiographs in minimally displaced fractures and found that post-splinting radiographs of minimally displaced or nondisplaced fractures that do not undergo manipulation before/during immobilization do not provide helpful information but do lead to increased health care costs, radiation exposure, and emergency room waits. 7 They concluded that routine performance of post-splinting radiography in these cases should be discouraged.…”

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confidence: 99%

Routine Imaging after Operatively Repaired Distal Radius and Scaphoid Fractures: A Survey of Hand Surgeons

et al. 2014

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).Imaging contributes substantially to the rising cost of health care. 1 Among surgical specialists, orthopaedic surgeons order a particularly high volume of imaging. Radiographic series are regularly taken during the initial evaluation of a patient, during preoperative planning, while the operation is under way, immediately after the operation, and at intervals throughout postoperative follow-up. In addition to the financial burden, imaging is associated with patient and staff time and exposure to radiation. AbstractBackground There is currently no standard of care for imaging after hand and upperextremity procedures, and current imaging practices have not been characterized. Questions/Purposes To characterize current imaging practices and to compare those practices to the best available evidence.Patients and Methods A survey was distributed to attending-level surgeons at a regional hand and upper-extremity surgery conference in the United States in 2013. 40 out of 75 surgeons completed the survey (53%).Results All results are presented for distal radius and scaphoid fractures, respectively. There was a high degree of variability between respondents in the number of radiographic series routinely ordered during follow-up of asymptomatic patients, with the number of series ranging from 1-6 and 1-6. On average, respondents did not order an excessive number of follow-up radiographs for asymptomatic patients, with means (AE standard deviations) of 2.6 AE 1.0 and 3.3 AE 1.2 radiographic series. Radiographic series were taken at only 74% and 81% of postoperative visits with asymptomatic patients. Only 10% and 8% of respondents felt it was acceptable medical practice to save costs by ordering postoperative radiographs only when patients are symptomatic.Conclusions Among a sample of 40 fellowship-trained hand surgeons, these findings demonstrate a high degree of variability in number of radiographs obtained after operative repair of distal radius and scaphoid fractures. On average, respondents were relatively efficient with respect to total number of postoperative radiographs ordered. Level of Evidence Diagnostic study, level IV.

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The impact of digitisation of a virtual fracture clinic on referral quality, outcomes and assessment times

Sephton

Morley

Mahapatra

et al. 2021

Eur J Trauma Emerg Surg

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Post-Splinting Radiographs of Minimally Displaced Fractures: Good Medicine or Medicolegal Protection?

Cited by 26 publications

References 10 publications

WARRIOR-trial - is routine radiography following the 2-week initial follow-up in trauma patients with wrist and ankle fractures necessary: study protocol for a randomized controlled trial

WARRIOR-trial - is routine radiography following the 2-week initial follow-up in trauma patients with wrist and ankle fractures necessary: study protocol for a randomized controlled trial

Routine Imaging after Operatively Repaired Distal Radius and Scaphoid Fractures: A Survey of Hand Surgeons

The impact of digitisation of a virtual fracture clinic on referral quality, outcomes and assessment times

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