Discussion
In this rapid review, designed to synthetize the published evidence on
potentially low value practices in orthopeadic trauma, we found
consistent evidence of lack of effectiveness or harm for the following
practices: routine initial imaging of the spine (<65 years of
age), pelvis, knee and ankle in patients negative on a validated
clinical decision rules or physical exam; preoperative blood tests in
ASA grade I patients; spine consultation for isolated thoracolumbar
transverse process fracture; immobilization with an orthosis in patients
<60 years of age with A0-A3 thoracolumbar burst fractures;
immobilization with a cast or splint for suspected scaphoid fracture
negative on MRI or confirmed fifth metacarpal neck fracture; and routine
follow-up X-ray in patients with clavicle, hip, femur, tibia, ankle or
metatarsal fractures.
Studies on initial imaging of the cervical spine, pelvis, knee and
ankle, consistently observed very small proportions of missed fractures
in patients at low risk on validated decision rules. In addition,
performing preoperative blood tests in ASA grade I patients did not lead
to any adjustment in therapies. However, these results were largely
based on systematic reviews of observational studies. Thus, high quality
RCTs may be needed to confirm that these practices are low-value.
Evidence for wrist imaging was less consistent with one study observing
10% of missed injuries.87 However, this evidence was
based on three prospective studies conducted in patients with similar
types of fractures but using different decision
rules.40,54,87 This suggests that more rigorous
research is needed to identify the most accurate clinical decision rule
for initial imaging of the wrist.
Studies on initial consultation and therapeutic interventions provided
consistent evidence of low-value care. Lack of spine surgeon
consultation for isolated T1 to L5 transverse process fracture was not
associated with neurological deficit. Importantly, none of the patients
in these studies required either surgery or an orthosis up to 6 months
post-injury, which are two treatments overseen by spine surgeons. Thus,
these patients could potentially be discharged with recommendations for
pain management and return to activities without a spinal surgery
consultation in the presence of sufficient expertise in radiological
interpretation. We found high-level evidence from systematic reviews of
RCTs and RCTs suggesting that orthosis in patients <60 years
of age with a A0-A3 thoracolumbar burst fracture and no neurological
symptoms is associated either with no benefit or with harm. Orthosis is
often prescribed to improve patient comfort but restricts patients’
movements causing discomfort and compromising sleep, which may explain
why patients with no orthosis had less or equivalent disability.
Similarly, we found high-level evidence from RCTs that immobilization of
the fifth metacarpal neck fractures leads to greater or equivalent
disability while immobilizing suspected scaphoid fractures is associated
with greater disability. Thus, evidence suggests that limiting the
mobility of patients with these injuries is not beneficial and may even
cause harm.
Some inconsistencies in evidence were observed for post-treatment
routine imaging and follow-up consultations. Fractures to the upper
extremities, particularly fractures to the radius shaft and metacarpal
were associated with high rates of immobilization prolongation in two
studies in which routine imaging was performed.46,64Also, except for the clavicle, high proportions of conversion to
operative management were observed for upper extremity fractures.
However, these findings were based on case series in which it wasn’t
always clear whether included patients had no clinical indication for
post-treatment imaging, such as persistent pain. One RCT conducted in
patients with distal radius fractures did not show a difference in
complications or functional recovery in patients with a reduced imaging
approach.82 We found consistent evidence for routine
follow-up X-rays and consultations for lower extremity fractures (i.e.,
hip, femur, tibia, ankle, metatarsal); these practices were not
associated with important changes in management or significant
differences in complications or functional recovery when compared to
selective use. However, apart from one RCT conducted in patients with
ankle fractures84, these findings were mainly observed
in case series. Globally, these results suggest that the number of
follow-up X-rays should be questioned.