Effect of a Protocol to Reduce Radiographic Imaging in Pediatric Patients With Suspected Fractures.

BACKGROUND: Children with suspected fractures are typically evaluated with multiple x-rays. This approach can add time, discomfort, and radiation exposure without clinical benefit. The purpose of this study was to determine whether a focused radiographic protocol could reduce the number of x-rays performed without missing any fractures. METHODS: Pediatric patients presenting at 2 sites within an academic medical center [urgent care (UC) and the emergency department(ED)] for a suspected fracture were identified. There were 495 patients (UC, 409; ED, 86) over a 3-month period. A retrospective chart review was performed to characterize the standard x-rays performed. Using this data, a simplified protocol was developed and distributed. Subsequently, 333 patients (UC, 259; ED, 74) were evaluated over the same period 1-year later. The main outcome measures included the final diagnosis, the total number of x-rays, the number of anatomic areas imaged, visit length, and the time for additional trips to radiology. Charts were reviewed to identify any missed injuries. Welch 2-sample t tests and Fisher exact tests were used for statistical analysis. RESULTS: After implementing the radiographic protocol, there was a significant reduction in the number of x-ray views, 3.4 versus 5.1 ( P <0.001). There was a decrease in imaging of multiple anatomic areas with the largest reduction occurring in patients presenting with elbow injuries (9% vs. 44%, P <0.001). No difference was found in the rate of patients sent back to radiology (6% vs. 7%, P =0.67). However, among patients presenting with outside imaging, significantly fewer were sent to radiology for additional x-rays (29% vs. 50%, P <0.01). CONCLUSION: A simple radiographic protocol for evaluating pediatric patients with suspected fractures safely led to a decrease in the overall number of x-rays without missing any injuries. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Does a Good Cast Index Always Reflect a Good Cast?

OBJECTIVES: The cast index is the most commonly used measurement of cast quality in pediatric forearm fractures, with low values representing a good quality cast and higher values suggesting poor technique. However, in some instances the cast index may not accurately reflect cast quality. The purpose of this study was to critically evaluate the quality of casts deemed "good" or "bad" based on the cast index against other measurements in order to identify these examples. METHODS: Pediatric patients casted for a distal or midshaft forearm fracture were identified from a prospectively gathered database. There were 121 casts on 97 forearms. Measurements were made on forearm or wrist x-rays to calculate the cast index, gap index, and the anatomic dimensions of the forearm at the level of the fracture. Fisher's exact test was used to assess the likelihood of a good cast index (< 0.75) to also have an acceptable gap index (< 0.15). Pearson's correlation compared the anatomic measurements of the forearm and the cast index. RESULTS: There were 65 casts with a good cast index, and 58% also had an acceptable gap index (< 0.15). Among the 56 casts with a bad cast index, 20% had an acceptable gap index (p < 0.001). The anatomic measurements of the forearm and the cast index were strongly correlated (r = 0.96). CONCLUSION: Many casts with a good cast index have an unacceptable gap index. Forearm measurements and cast index are highly correlated, suggesting that a well-molded cast may have a higher cast index due to the shape of the forearm. While the cast index is a useful tool, "good" or "bad" casts are not uniformly captured by this measurement.