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Scientific Articles   |    
Post-Splinting Radiographs of Minimally Displaced Fractures: Good Medicine or Medicolegal Protection?
Sonia Chaudhry, MD1; Edward M. DelSole, BS1; Kenneth A. Egol, MD1
1 NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. E-mail address for S. Chaudhry: chaudhry85@gmail.com
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Investigation performed at NYU Hospital for Joint Diseases, New York, NY, and Jamaica Hospital Medical Center, Jamaica, New York



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Sep 05;94(17):e128 1-5. doi: 10.2106/JBJS.K.00944
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Abstract

Background: 

Many institutions perform radiographic documentation following splint application even when no manipulation had been performed. The purpose of this study was to evaluate the utility of post-splinting radiographs of acute non-displaced or minimally displaced fractures that did not undergo manipulation. Our hypothesis was that post-splinting radiographs do not demonstrate changes in fracture alignment or impact the management of the patient.

Methods: 

After institutional review board exemption had been granted, consultations performed by orthopaedic residents at a level-I trauma center from September 2008 to April 2010 were reviewed. Of 2862 consultations, 1321 involved acute fractures that were splinted. Radiographs revealed that 342 (25.9%) of the fractures were non-displaced or minimally displaced and angulated (defined as <5 mm and <10°, respectively) and 204 of them had been assessed with radiographs after splinting. Consults were reviewed to ensure that the patients had not undergone manipulation prior to or during splinting. Consult notes and radiographs obtained in the emergency room (ER), as well as follow-up radiographs, were reviewed to assess ultimate outcome.

Results: 

None of the 204 fractures (134 non-displaced and seventy minimally displaced) changed alignment following splinting. Two splints were reapplied, and the fractures sites were reimaged for undocumented reasons. Patients were subjected to an average of ten radiographs (range, four to twenty-five radiographs) of their extremities in the acute setting. On average, three post-splinting radiographs (range, one to ten radiographs) were obtained. The mean time between the initial and post-splinting radiographs was three hours and thirty minutes (range, nine minutes to twenty-four hours). The most common injury was a fracture about the hand or wrist. The 122 patients with that type of injury waited an average of almost three hours for an average of three post-splinting radiographs, contributing to a total of nine radiographs performed acutely. ER visits tended to be longer for patients with post-splinting radiographs compared with those without them (p = 0.06). Follow-up radiographs were available for eighty-two patients. All fractures demonstrated maintained alignment.

Conclusions: 

Post-splinting radiographs of non-displaced and minimally displaced fractures that do not undergo manipulation before or during immobilization are associated with longer ER waits, additional radiation exposure, and increased health-care costs without providing helpful information. While certain circumstances call for additional imaging, routine performance of post-splinting radiography of non-displaced or minimally displaced fractures should be discouraged.

Level of Evidence: 

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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