Fractures of both the upper and lower extremities

Two studies found no changes in treatment strategy for post-splinting and post-operative radiographs of both the upper and lower extremities.

Schuld et al. [17] (NOS 5/9) examined the effect of imaging on the treatment of 265 non-displaced fractures of the hand, wrist, ankle, or foot. They examined the number of dislocations during the splinting procedure on post-splinting X-rays (n = 27) and the number of secondary dislocations in patients with follow-up radiographs obtained at the outpatient clinic (n = 179). No changes in management based on post-splinting radiographs were identified. Secondary dislocation was observed in of 7.8% of participants (n = 14). Treatment strategy was unaltered in all of these patients. Based on these findings, post-splinting radiographs were labelled “likely unnecessary”, and the authors stated that repeat imaging in this patient group should be discouraged.

Ghattas et al. [18] (NOS 4/9) assessed the influence of radiographs on the treatment strategy of extremity fractures that were treated with surgical fixation in a retrospective, 2-year cohort. In total, 200 fractures in 171 patients were included. All changes to normal post-operative management (i.e., all procedures or interventions not typically used in the aftercare of that specific fracture) at the initial outpatient clinic visit were identified. Over a mean follow-up period of 24 days (range 7–61 days), 3 out of 200 fractures had a change in treatment strategy. All three changes were based on clinical symptoms, rather than on the radiographs. The authors concluded that radiographs at the initial post-operative outpatient clinic visit do not alter treatment strategy, but do pose a financial burden.

Fractures of the lower extremity

Four studies showed that radiographs of the lower extremity do not change treatment strategy, do not have an impact on complications, and should not be obtained if there are no clinical signs of a complication.

McDonald et al. [19] (NOS 6/9) studied the number of complications in relation to the timing of the first post-operative radiograph in a retrospective cohort of 1411 operatively treated ankle fractures. They divided this cohort in two groups. The first group had their initial follow-up radiograph taken in the first 3 weeks following surgery; the second received their initial follow-up radiograph more than 3 weeks after the intervention. They observed 62 complications in 889 patients with ‘early’ radiographs (7.0%), and 31 complications in 522 patients with radiographs solely obtained more than 3 weeks after surgery (5.9%). This difference was not statistically significant. The researchers concluded that obtaining early routine radiographs (i.e., in the first 3 weeks following surgery) for all patients with an ankle fracture is of questionable benefit.

Ovaska et al. [20] (NOS 5/9) evaluated the number of changes in treatment strategy based on radiographs obtained at the first scheduled outpatient clinic visit in a retrospective cohort of 878 patients with an operatively treated ankle fracture. In three out of 878 patients (0.3%), a change in treatment strategy was observed solely based on a routine radiograph. All of these changes were adjustments in weight bearing regimen, either after an initially undiagnosed medial malleolus fracture, or after subtle secondary dislocation. The authors concluded that routine radiographs should probably not be obtained at the first outpatient clinic visit if no clinical signs of a complication are present.

Kempegowda et al. [21] (NOS 5/9) assessed a cohort of 465 patients with healed intertrochanteric fractures with a mean follow-up period of 81 weeks. The main outcome measure was a radiological change on radiographs obtained after clinical and radiological union had already been demonstrated earlier on. On average, patients had 2.8 outpatient clinic visits, and 2.6 radiographs after union had been confirmed. Of these radiographs, 98% did not reveal changes when compared to previous imaging. Three images (0.7%) showed signs of avascular necrosis of the femoral head, three showed osteoarthritis of the hip, and three revealed heterotopic ossification. The authors concluded that there is a negligible role for radiographs and clinic visits when evidence of clinical and radiographic healing with acceptable alignment of an intertrochanteric fracture is available.

Robertson et al. [22] (NOS 3/9) retrospectively evaluated 53 patients with an isolated tibial shaft fracture that were treated with an intramedullary nail. Out of 343 radiographs obtained during follow-up, nine (3%) directly led to a change in clinical management. In two patients, radiographs showed union, and the nail was removed. The remaining seven patients showed signs of delayed union, which gave rise to nail exchange procedures. The authors concluded that serial radiographs are not justified, and that radiographs prior to 10-week follow-up should only be obtained when there is a clinical suspicion of a complication.

Fractures of the upper extremity

Five studies showed that follow-up radiographs of the upper extremity seldom influenced treatment strategy, should only be obtained on a clinical indication and that routine radiography can probably be omitted.

Weil et al. [23] (NOS 5/9) evaluated the use of routine radiographs, and the changes in treatment strategy based on these radiographs, taken after more than 3 weeks of follow-up in a multi-center cohort of 1042 patients with a distal radius fracture. A radiograph was labelled routine if no clinical indication for obtaining it was registered in the medical records. Of the 720 radiographs that complied with these requirements, 11 (1.5%) led to a change in treatment strategy. In nine instances, cast immobilization was prolonged, and in two instances, the patient was converted to operative treatment. The conclusion of the authors was that routine radiographs after the initial 3-week follow-up period seldom influence clinical decision making.

Stone et al. [24] (NOS 5/9) studied radiographs taken 2 weeks after open reduction and internal fixation of distal radius fractures in a retrospective cohort of 261 patients with 268 fractures. They evaluated the number of changes in treatment strategy as well as the number of re-interventions. At 2-week follow-up, three changes in management were recorded (1.1%). All of these cases involved patients with a loss of reduction or hardware failure after a consecutive trauma to the injured wrist. The authors concluded that for low-energetic, non-comminuted fractures, routine radiographs at 2 weeks could be omitted.

Huffaker et al. [25] (NOS 5/9) evaluated the value of routine post-operative radiographs in AO type A [28] distal radius fractures treated with volar locking plates. They identified 446 post-operative radiographs in a cohort of 158 patients. During follow-up (mean 4.2 months), none of the radiographs showed non-union, loss of fixation or a change in alignment. For patients presenting with symptoms (such as neuropathy, signs of infection, pain, or crepitation), radiography was not associated with a higher likelihood of operative intervention. The authors concluded that radiographs, apart from the primary direct post-operative radiograph, should only be obtained for a clinical indication.

Eastley et al. [26] (NOS 5/9) assessed 137 patients with extra-articular distal radius fractures that were treated non-operatively. They investigated whether grip strength, clinical deformity, and range of motion were associated with obtaining radiographs after more than 2 weeks of follow-up. The cohort was divided into two groups. One that had radiographs taken only in the first 2 weeks (‘early’ n = 77), and another group that had follow-up radiographs beyond this term as well (‘late’ n = 61). No significant differences in grip strength, mean flexion, dorsiflexion, radial deviation, and ulnar deviation were found. There was no conversion to operative care based on late radiographs. The authors concluded that omission of late radiographs in this patient category may have no adverse effects on clinical outcome whilst providing financial benefits.

De Beaux et al. [27] (NOS 4/9) evaluated a retrospective cohort of 45 patients with a suspected fracture of the elbow region (depicted by a positive fat pad sign, but the absence of a fracture line on the initial emergency room radiographs). The main research question was if repeat radiography after 2-week altered treatment strategy. At the 2-week follow-up moment, 11 patients failed to attend and 3 had no repeat radiographs made. Of the remaining 31 patients, 29 had normal radiographs, and 2 patients were diagnosed with a non-displaced fracture of the radial head. No changes were made to the treatment of any participant. The authors concluded that routine follow-up radiography is unnecessary in this patient category.