- Email: [email protected]
Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary
YAJEM-55780; No of Pages 2 American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
F
Q24Q1
Jill C. Schuld, MD a,⁎, Mark L. Volker b, Sarah A. Anderson, MD c, Michael D. Zwank, MD a
5 6 7
a
8
a r t i c l e
15 9 10 11 12 13
Article history: Received 23 March 2016 Received in revised form 20 April 2016 Accepted 2 May 2016 Available online xxxx
b
Emergency Medicine Department, Regions Hospital, Saint Paul, MN Regions Hospital Critical Care Research Center, Saint Paul, MN Department of Orthopedic Surgery, Regions Hospital, Saint Paul, MN
i n f o
a b s t r a c t
Background: Acute nondisplaced fractures (NDFs) are common in the emergency department (ED), and providers often obtain postsplinting x-rays to identify displacement that potentially occurs during the splinting process. Our objectives are to (1) determine how often x-rays are obtained after splinting of NDFs, (2) identify if postsplinting x-rays change treatment management in the ED, and (3) identify if there are medical complications at follow-up. Methods: A retrospective chart review of ED patients who were discharged with hand, wrist, ankle, or foot fractures was conducted to determine patients with definite NDFs that were verified by a radiologist, underwent splinting, and either had postsplint x-rays or not. Bone displacement during the splinting procedure was determined by the postsplint x-rays in the ED. Internal movement of bones or management change was also determined for patients who did not undergo postsplint x-rays in the ED but had obtained an x-ray at their followup visit (in-network providers only). Results: Our results demonstrate that no patients required further manipulation or operative management due to the splinting that occurred in the ED. These results take into account both patients who had postsplint x-rays conducted in the ED (27 patients) and those who received x-rays in follow-up consults (179 patients). There was minimal incidence of interval movement in the latter group (14 patients), none of which resulted in management change. Conclusion: These data conclude that postsplinting x-rays of NDFs are unnecessary. Removal of this procedure from routine practice will help decrease patient and hospital cost, time, and radiation exposure. © 2016 Published by Elsevier Inc.
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Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary
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Brief Report
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1. Introduction
35
Acute fractures are common injuries in the emergency department (ED) setting, accounting for thousands of visits each year [1]. The standard of care among both ED and orthopedic physicians is to perform adequate reduction followed by placement of a plaster or fiberglass splint to maintain reduction. There are generally 2 types of closed fractures seen in the ED setting: displaced and nondisplaced. Displaced fractures will frequently require closed reduction before splint placement followed by postreduction radiographs to ensure adequate alignment and proper reduction. In nondisplaced fractures (NDFs), however, the bones are already in proper anatomic alignment, and splint application is performed to immobilize the bone during the healing process. Although it is common practice to obtain radiographs after closed
38 39 40 41 42 43 44 45 46
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⁎ Corresponding author at: Regions Hospital Emergency Medicine Residency, 640 Jackson Street MS11102F, Saint Paul, MN 55101. E-mail address: [email protected] (J.C. Schuld).
reduction and manipulation, the role of radiographs after splinting for NDFs remains controversial. Many ED physicians continue to obtain postsplinting radiographs for NDFs as assurance that the fracture segments have not moved during splint application. However, there have been few systematic reviews studying the necessity of postsplinting x-rays or their contribution to change in management. In addition, it has been suggested that postsplinting radiographs in NDFs have led to increased costs, radiation, and time spent in the ED without added benefit. Chaudhry et al [2] looked at the utility of postsplinting radiographs for nondisplaced or minimally displaced fractures among orthopedic physicians consulted in the ED. He found that among 204 minimally displaced fractures, none had changed alignment after splinting, suggesting that postsplinting films are probably unnecessary. As long bone fractures are more likely to be displaced or require surgical management, our study focuses on small bone fractures of the hand, wrist, ankle, and foot. Our objectives are (1) to determine how often x-rays are obtained after splinting of NDFs of the hand, wrist, ankle, or foot; (2) to identify if obtaining postsplinting x-rays in patients with NDFs changes their treatment management in the ED; and (3) to identify if fracture
http://dx.doi.org/10.1016/j.ajem.2016.05.001 0735-6757/© 2016 Published by Elsevier Inc.
Please cite this article as: Schuld JC, et al, Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.001
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66
96 97
After institutional review board approval was obtained, a retrospective chart review was performed that included a cohort of patients discharged from the ED between September 1, 2013, and August 31, 2014, with a diagnosis of the following fractures: metacarpal, cuboid, or scaphoid fractures(hand); distal radius, distal ulna, or distal radius/ ulna fractures (wrist); distal tibia, distal fibula, lateral malleolus, medial malleolus, bimalleolar, or calcaneus fractures (ankle); or a metatarsal fracture (foot). Inclusion criteria were patients presenting with acute injury who underwent initial radiographic imaging and were found to have an NDF as verified by the reading radiologist who then underwent splinting with plaster or fiberglass. Patients were excluded if they had a displaced fracture that required manual reduction if they were placed in a prefabricated boot or splint or if they were not splinted. Electronic medical records were then reviewed by trained research assistants to determine patients with NDFs as determined by the reading radiologist and underwent splinting. Splinting was performed by an ED physician, resident, or physician assistant. Two groups were then identified: Patients who received postsplint x-rays and those who did not (238 patients). In those patients who underwent postsplint x-rays, we reviewed whether bones became displaced during the splinting procedure as determined by the postsplint x-ray radiology read. For the group that did not undergo postsplint x-rays in the ED, we reviewed whether patients obtained an x-ray at their follow-up visit within 2 months of the initial ED visit (in-network providers only). We then identified whether patients had interval fracture displacement or management change based on the follow-up x-ray, orthopedic progress note, and radiology read.
98
3. Results
99
121 122
Of the 265 patients who met study criteria, 138 were male and 127 were female. The median age of patients was 34 years old with a range from 1 to 91 years of age. Nondisplaced fracture types by category included 78 wrist (29.4%), 77 ankle (29.1%), 63 hand (23.8%), and 47 foot (17.7%). Of the 265 patients who met study criteria, 27 (20.19%) had postsplinting radiographs performed before discharge. The postsplinting radiographs did not change management in any of these cases. A total of 204 patients (77.0%) followed up within our clinic system. The median time to follow-up was 9 days with a range of 1 to 139 days. A total of 179 patients (87.8%) had repeat radiographs at follow-up which were read by both the orthopedic physician and a radiologist. Fourteen patients (7.8%) had interval displacement of their bones on repeat radiographs—4 hand, 2 wrist, 4 ankle, and 4 foot. In 13 of these patients, there was no change in management based on the repeat imaging results. The 1 patient requiring surgical intervention had a bimalleolar fracture on his original ED x-ray. Postsplinting radiographs were obtained before ED discharge, and imaging was reviewed by the on-call orthopedic surgeon. Although the fracture was nondisplaced on postsplinting films in the ED, it was felt to be an unstable fracture pattern so plan on discharge was for surgical intervention upon follow-up. Decision for operative intervention was made by the orthopedic surgeon was felt to be unrelated to splinting and postsplinting radiographs.
123
4. Discussion
124 125
Approximately 20% of all patients with NDFs obtained postsplint xrays in the ED before discharge despite that fact that no manual
84 85 86 87 88 89 90 91 92 93 94 95
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71 72
References
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[1] Orces C. Emergency department visits for fall-related fractures among older adults in the USA: a retrospective cross-sectional analysis of the national electronic injury surveillance system all injury program, 2001-2008. BMJ Open 2013;3:e00122. [2] Chaudhry S, DelSole EM, Egol KA. Post-splinting radiographs of minimally displaced fractures: good medicine or medicolegal protection. J Bone Joint Surg Am 2012; 94(1–5):e238. [3] Farbman KS, Vinci RJ, Cranley WR, Creevy WR, Bauchner H. The role of serial radiographs in the management of pediatric torus fractures. Arch Pediatr Adolesc Med 1999;153(9):923–5. [4] Kakarlapudi TK, Santini A, Shahane SA, Douglas D. The cost of treatment of distal radial fractures. Injury 2000;31(4):229–32.
181 182 183 Q3 184 185 186 Q4 187 188 189 190 191
F
70
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2. Methods
126
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manipulation of the fracture was performed. In this cohort of patients, there was no change in immediate ED management after repeat radiographs. Our findings support previous research by Chaudhry et al [2] who found no management change in postsplint x-rays of NDFs by orthopedic providers. This suggests that postsplint radiographs are likely unnecessary and potentially harmful, increasing the risk of patient radiation and ED length of stay. The decision for postsplinting x-rays, however, must be made on a case-by-case basis. This is especially true of ankle fractures as recognition of unstable fracture patterns even among NDFs can be difficult. In such cases, consultation with an orthopedic surgeon to review imaging before discharge may be of benefit. Of the 265 patients who had NDFs splinted in the ED, 204 patients (77%) followed up as instructed with an in-network orthopedic provider. Approximately 88% of these patients had repeat radiographs during their follow-up visit. Only 14 patients (7.8%) had interval movement on repeat radiographs, all of which had no change in management based on repeat imaging results. One patient with a bimalleolar fracture that had interval displacement did require surgical intervention that had been previously anticipated. With the growing problem of increased ED visits and cost of health care, there is an appropriately heavy focus on improving patient care while reducing hospital length of stay and unnecessary testing. Postreduction imaging of NDFs has remained a controversial topic in health care, often enacted by both orthopedic and ED providers to avoid medicolegal consequences or to provide perceived standard of care. There have been only a few studies focusing on the necessity (or lack thereof) of postreduction films in NDFs. The largest, performed by Chaudhry et al, looked at 204 nondisplaced or minimally displaced fractures, 60% of which underwent postsplinting x-rays without change in management. These patients had significantly increased length of stay in the ED and an average of 9 total radiographs performed acutely, leading to increased cost and radiation at no obvious benefit [2]. Several smaller studies focused on particular fracture patterns found similar results [3,4]. Our study does have several limitations. First, this was a retrospective chart review performed at a single level 1 trauma center with staff physicians, resident physicians, and physician assistants on staff. There are no uniform guidelines at this facility regarding postsplinting x-rays so the decision is left to individual preference. In the 20% of patients who underwent postsplinting x-rays, there was no documentation on why the decision was made so extraneous circumstances or concern during the splinting process cannot be excluded. In addition, only 75% of patients who presented to the ED followed up within our health care network. It is uncertain if the remaining 25% were seen within other systems or if they did not follow-up at all. Finally, although previous studies have suggested increased length of stay, radiation, and cost with repeat imaging, our study did not focus on these numbers so our results can only be generalized based on previous data. Future randomized multicenter trials may provide further insights. Despite these limitations, however, our study supports the fact that postsplinting x-rays for NDFs in the ED setting do not change management decisions and are likely unnecessary. Given the costs and potentially harmful radiation, repeat imaging should be carefully considered on a case-by-case basis and discouraged as standard of care.
P
displacement or other complications occur at the follow-up clinic visit in patients that do not receive postsplinting x-rays.
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68
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J.C. Schuld et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
E
2
Please cite this article as: Schuld JC, et al, Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.001
127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
F
Q24Q1
Jill C. Schuld, MD a,⁎, Mark L. Volker b, Sarah A. Anderson, MD c, Michael D. Zwank, MD a
5 6 7
a
8
a r t i c l e
15 9 10 11 12 13
Article history: Received 23 March 2016 Received in revised form 20 April 2016 Accepted 2 May 2016 Available online xxxx
b
Emergency Medicine Department, Regions Hospital, Saint Paul, MN Regions Hospital Critical Care Research Center, Saint Paul, MN Department of Orthopedic Surgery, Regions Hospital, Saint Paul, MN
i n f o
a b s t r a c t
Background: Acute nondisplaced fractures (NDFs) are common in the emergency department (ED), and providers often obtain postsplinting x-rays to identify displacement that potentially occurs during the splinting process. Our objectives are to (1) determine how often x-rays are obtained after splinting of NDFs, (2) identify if postsplinting x-rays change treatment management in the ED, and (3) identify if there are medical complications at follow-up. Methods: A retrospective chart review of ED patients who were discharged with hand, wrist, ankle, or foot fractures was conducted to determine patients with definite NDFs that were verified by a radiologist, underwent splinting, and either had postsplint x-rays or not. Bone displacement during the splinting procedure was determined by the postsplint x-rays in the ED. Internal movement of bones or management change was also determined for patients who did not undergo postsplint x-rays in the ED but had obtained an x-ray at their followup visit (in-network providers only). Results: Our results demonstrate that no patients required further manipulation or operative management due to the splinting that occurred in the ED. These results take into account both patients who had postsplint x-rays conducted in the ED (27 patients) and those who received x-rays in follow-up consults (179 patients). There was minimal incidence of interval movement in the latter group (14 patients), none of which resulted in management change. Conclusion: These data conclude that postsplinting x-rays of NDFs are unnecessary. Removal of this procedure from routine practice will help decrease patient and hospital cost, time, and radiation exposure. © 2016 Published by Elsevier Inc.
D
c
O
3
Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary
R O
2
Brief Report
P
1
R R
E
C
T
E
14
1. Introduction
35
Acute fractures are common injuries in the emergency department (ED) setting, accounting for thousands of visits each year [1]. The standard of care among both ED and orthopedic physicians is to perform adequate reduction followed by placement of a plaster or fiberglass splint to maintain reduction. There are generally 2 types of closed fractures seen in the ED setting: displaced and nondisplaced. Displaced fractures will frequently require closed reduction before splint placement followed by postreduction radiographs to ensure adequate alignment and proper reduction. In nondisplaced fractures (NDFs), however, the bones are already in proper anatomic alignment, and splint application is performed to immobilize the bone during the healing process. Although it is common practice to obtain radiographs after closed
38 39 40 41 42 43 44 45 46
U N C
36 37
O
34
⁎ Corresponding author at: Regions Hospital Emergency Medicine Residency, 640 Jackson Street MS11102F, Saint Paul, MN 55101. E-mail address: [email protected] (J.C. Schuld).
reduction and manipulation, the role of radiographs after splinting for NDFs remains controversial. Many ED physicians continue to obtain postsplinting radiographs for NDFs as assurance that the fracture segments have not moved during splint application. However, there have been few systematic reviews studying the necessity of postsplinting x-rays or their contribution to change in management. In addition, it has been suggested that postsplinting radiographs in NDFs have led to increased costs, radiation, and time spent in the ED without added benefit. Chaudhry et al [2] looked at the utility of postsplinting radiographs for nondisplaced or minimally displaced fractures among orthopedic physicians consulted in the ED. He found that among 204 minimally displaced fractures, none had changed alignment after splinting, suggesting that postsplinting films are probably unnecessary. As long bone fractures are more likely to be displaced or require surgical management, our study focuses on small bone fractures of the hand, wrist, ankle, and foot. Our objectives are (1) to determine how often x-rays are obtained after splinting of NDFs of the hand, wrist, ankle, or foot; (2) to identify if obtaining postsplinting x-rays in patients with NDFs changes their treatment management in the ED; and (3) to identify if fracture
http://dx.doi.org/10.1016/j.ajem.2016.05.001 0735-6757/© 2016 Published by Elsevier Inc.
Please cite this article as: Schuld JC, et al, Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.001
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66
96 97
After institutional review board approval was obtained, a retrospective chart review was performed that included a cohort of patients discharged from the ED between September 1, 2013, and August 31, 2014, with a diagnosis of the following fractures: metacarpal, cuboid, or scaphoid fractures(hand); distal radius, distal ulna, or distal radius/ ulna fractures (wrist); distal tibia, distal fibula, lateral malleolus, medial malleolus, bimalleolar, or calcaneus fractures (ankle); or a metatarsal fracture (foot). Inclusion criteria were patients presenting with acute injury who underwent initial radiographic imaging and were found to have an NDF as verified by the reading radiologist who then underwent splinting with plaster or fiberglass. Patients were excluded if they had a displaced fracture that required manual reduction if they were placed in a prefabricated boot or splint or if they were not splinted. Electronic medical records were then reviewed by trained research assistants to determine patients with NDFs as determined by the reading radiologist and underwent splinting. Splinting was performed by an ED physician, resident, or physician assistant. Two groups were then identified: Patients who received postsplint x-rays and those who did not (238 patients). In those patients who underwent postsplint x-rays, we reviewed whether bones became displaced during the splinting procedure as determined by the postsplint x-ray radiology read. For the group that did not undergo postsplint x-rays in the ED, we reviewed whether patients obtained an x-ray at their follow-up visit within 2 months of the initial ED visit (in-network providers only). We then identified whether patients had interval fracture displacement or management change based on the follow-up x-ray, orthopedic progress note, and radiology read.
98
3. Results
99
121 122
Of the 265 patients who met study criteria, 138 were male and 127 were female. The median age of patients was 34 years old with a range from 1 to 91 years of age. Nondisplaced fracture types by category included 78 wrist (29.4%), 77 ankle (29.1%), 63 hand (23.8%), and 47 foot (17.7%). Of the 265 patients who met study criteria, 27 (20.19%) had postsplinting radiographs performed before discharge. The postsplinting radiographs did not change management in any of these cases. A total of 204 patients (77.0%) followed up within our clinic system. The median time to follow-up was 9 days with a range of 1 to 139 days. A total of 179 patients (87.8%) had repeat radiographs at follow-up which were read by both the orthopedic physician and a radiologist. Fourteen patients (7.8%) had interval displacement of their bones on repeat radiographs—4 hand, 2 wrist, 4 ankle, and 4 foot. In 13 of these patients, there was no change in management based on the repeat imaging results. The 1 patient requiring surgical intervention had a bimalleolar fracture on his original ED x-ray. Postsplinting radiographs were obtained before ED discharge, and imaging was reviewed by the on-call orthopedic surgeon. Although the fracture was nondisplaced on postsplinting films in the ED, it was felt to be an unstable fracture pattern so plan on discharge was for surgical intervention upon follow-up. Decision for operative intervention was made by the orthopedic surgeon was felt to be unrelated to splinting and postsplinting radiographs.
123
4. Discussion
124 125
Approximately 20% of all patients with NDFs obtained postsplint xrays in the ED before discharge despite that fact that no manual
84 85 86 87 88 89 90 91 92 93 94 95
100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120
C
82 83
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80 81
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76 77
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73 74
U
71 72
References
180
[1] Orces C. Emergency department visits for fall-related fractures among older adults in the USA: a retrospective cross-sectional analysis of the national electronic injury surveillance system all injury program, 2001-2008. BMJ Open 2013;3:e00122. [2] Chaudhry S, DelSole EM, Egol KA. Post-splinting radiographs of minimally displaced fractures: good medicine or medicolegal protection. J Bone Joint Surg Am 2012; 94(1–5):e238. [3] Farbman KS, Vinci RJ, Cranley WR, Creevy WR, Bauchner H. The role of serial radiographs in the management of pediatric torus fractures. Arch Pediatr Adolesc Med 1999;153(9):923–5. [4] Kakarlapudi TK, Santini A, Shahane SA, Douglas D. The cost of treatment of distal radial fractures. Injury 2000;31(4):229–32.
181 182 183 Q3 184 185 186 Q4 187 188 189 190 191
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manipulation of the fracture was performed. In this cohort of patients, there was no change in immediate ED management after repeat radiographs. Our findings support previous research by Chaudhry et al [2] who found no management change in postsplint x-rays of NDFs by orthopedic providers. This suggests that postsplint radiographs are likely unnecessary and potentially harmful, increasing the risk of patient radiation and ED length of stay. The decision for postsplinting x-rays, however, must be made on a case-by-case basis. This is especially true of ankle fractures as recognition of unstable fracture patterns even among NDFs can be difficult. In such cases, consultation with an orthopedic surgeon to review imaging before discharge may be of benefit. Of the 265 patients who had NDFs splinted in the ED, 204 patients (77%) followed up as instructed with an in-network orthopedic provider. Approximately 88% of these patients had repeat radiographs during their follow-up visit. Only 14 patients (7.8%) had interval movement on repeat radiographs, all of which had no change in management based on repeat imaging results. One patient with a bimalleolar fracture that had interval displacement did require surgical intervention that had been previously anticipated. With the growing problem of increased ED visits and cost of health care, there is an appropriately heavy focus on improving patient care while reducing hospital length of stay and unnecessary testing. Postreduction imaging of NDFs has remained a controversial topic in health care, often enacted by both orthopedic and ED providers to avoid medicolegal consequences or to provide perceived standard of care. There have been only a few studies focusing on the necessity (or lack thereof) of postreduction films in NDFs. The largest, performed by Chaudhry et al, looked at 204 nondisplaced or minimally displaced fractures, 60% of which underwent postsplinting x-rays without change in management. These patients had significantly increased length of stay in the ED and an average of 9 total radiographs performed acutely, leading to increased cost and radiation at no obvious benefit [2]. Several smaller studies focused on particular fracture patterns found similar results [3,4]. Our study does have several limitations. First, this was a retrospective chart review performed at a single level 1 trauma center with staff physicians, resident physicians, and physician assistants on staff. There are no uniform guidelines at this facility regarding postsplinting x-rays so the decision is left to individual preference. In the 20% of patients who underwent postsplinting x-rays, there was no documentation on why the decision was made so extraneous circumstances or concern during the splinting process cannot be excluded. In addition, only 75% of patients who presented to the ED followed up within our health care network. It is uncertain if the remaining 25% were seen within other systems or if they did not follow-up at all. Finally, although previous studies have suggested increased length of stay, radiation, and cost with repeat imaging, our study did not focus on these numbers so our results can only be generalized based on previous data. Future randomized multicenter trials may provide further insights. Despite these limitations, however, our study supports the fact that postsplinting x-rays for NDFs in the ED setting do not change management decisions and are likely unnecessary. Given the costs and potentially harmful radiation, repeat imaging should be carefully considered on a case-by-case basis and discouraged as standard of care.
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displacement or other complications occur at the follow-up clinic visit in patients that do not receive postsplinting x-rays.
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68
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J.C. Schuld et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
E
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Please cite this article as: Schuld JC, et al, Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.001
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