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.