194 Challenging the Dogma of Radiographs a Joint Above and Below a Suspected Fracture: Quantification of Waste in Wrist Fracture Evaluation

Abstract

The dogmatic teaching and practice to obtain X-ray imaging of the joint above and below every suspected wrist fracture is ingrained in emergency medicine and orthopedics. Originally recommended in a 1975 abstract, based on no data, this idea has been perpetuated to the present. In the interest of patient cost, resource management, and throughput we questioned the utility of this knee jerk radiographic exploration. We assessed the probability of identifying fractures outside of the wrist x-ray when no tenderness to palpation was elicited beyond the wrist. We performed a retrospective medical record review of patients diagnosed with wrist fractures at an urban public aid academic hospital. Inclusion criteria: was ICD diagnosis of distal radius, distal ulna, or carpal bone fractures at discharge between April 2019 and April 2020. Patients were excluded if they were <18 years of age, GCS <15, documented tenderness to the hand, proximal forearm, elbow, or humerus, or follow up visits. The documented physical exams performed by ED providers and Orthopedic consults were reviewed to identify location of tenderness both at the wrist and elsewhere. Undocumented tenderness was assumed to be negative. Analysis was performed with descriptive statistics including 95% confidence intervals. 716 patient encounters were identified. After exclusions, the cohort included 345 unique patients who presented with only wrist tenderness. Of the 345 patients, 113 were between the ages 18-40, 193 were between 40-65, and 39 patients were over 65. 177 (51%) were female. Based on our exclusion criteria, this sample had no tenderness outside of the wrist. Still, there were 268 hand x-rays, 284 forearm x- rays, 77 elbow x-rays, and 21 humerus x-rays performed. There were zero additional fractures identified in this imaging beyond the wrist. Analysing the frequency and outcome of these additional x-rays allowed estimation of the upper limit of the 95% CI as a way of estimating the probability of identifying an additional fracture. Forearm radiographs identified 0 % additional fractures, (95% CI (0.0 to 1.3%)). Hand x-rays 0% (95% CI (0.0 to 1.4%). Wrist x-rays alone identified 345 distal radial fractures, 184 distal ulna fractures, 14 carpal bone fracture/dislocations, and 1 proximal metacarpal fracture. The proportion of patients with additional radiographs that identified a fracture not identified on wrist x-ray in this sample was zero. Based on sample size the potential miss rate is likely less than 2%. This argues against default image ordering above and below tenderness and may provide savings on time, radiation, and cost.