Decreasing Radiation Exposure in Pediatric Clavicle and Metatarsal Fractures: A QI Initiative

Abstract

Background: Protecting the pediatric population from unnecessary medical radiation is an important public health initiative. Efforts have been made to reduce radiation exposure in the treatment of pediatric fractures without compromising quality of care. Using a standardized protocol for imaging of pediatric clavicle and metatarsal fractures is a reliable method for reducing pediatric radiation exposure in the management of these fractures. Methods: In the year 2015, the senior author altered follow-up imaging practices for 2 common pediatric fractures: metatarsal and clavicular. Initial radiographic evaluation included the standard 3 views for metatarsal fractures and 2 views for clavicle fractures. This standard diagnostic procedure remained constant throughout the study. Follow-up x-rays from 2009 to 2014 routinely included 3 views of the foot and 2 views of the clavicle. The protocol was changed and from 2016 to 2019, follow-up x-rays for fractures routinely included 2 views of the foot and 1 view of the clavicle, thereby decreasing the number of x-rays utilized to manage these fractures. Results: There was a significant reduction in the number of clavicle x-rays (P<0.001) and metatarsal x-rays (P=0.004) taken in follow-up between the time-periods. Median values for metatarsal views decreased by 1, matching the adjustment in protocol. In addition, the vast majority of clavicle fractures (90.80%) were managed with 1 follow-up view in 2016 to 2019 compared with 2 views (72.48%) from 2009 to 2014. Conclusions: This study achieved a reduction in radiation exposure in pediatric patients with nonoperatively managed clavicle and metatarsal fractures. Improving the quality of care of patients through decreasing the number of x-rays taken protects individuals from adverse side effects, as well as offers various public health benefits in terms of reduction in expenditures. Level of Evidence: Level III—retrospective comparative study.

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

“…Our radiology department noted significant variability radiation, owing to patient size and distances in technique. Similar to a study by Brown et al, 4 we agree that radiation exposure in the pediatric population should be as low as reasonably achievable and that decreasing the total views follows this principle.…”

“…Ting et al13 reported that the number of follow-up visits and radiographs could be safely limited for pediatric greenstick fractures. The safety of limiting follow-up radiographs in other pediatrics fractures has also been verified, including clavicle and metatarsal fractures 4. Our findings contributed to the current literature on the reduction of radiation for pediatric fractures by demonstrating that initial radiographs can be safely limited to the injured area without including anatomic areas above and below.…”

“…1,2 Although thorough, this approach to imaging can add time to the visit, patient discomfort, and radiation exposure without providing clinical benefit. [3][4][5][6] Reducing radiation exposure in the pediatric population is an area of current research. This has included limiting follow-up radiographs, 7 applying ultrasound when possible, 8 and considering protocols for shielding.…”

“…Therefore, it is common practice to evaluate other anatomic areas such as the joint above and below 1,2. Although thorough, this approach to imaging can add time to the visit, patient discomfort, and radiation exposure without providing clinical benefit 3–6…”

Radiographic considerations for pediatric supracondylar humerus fractures

“…Trends in pediatric orthopedics have been to minimize radiation due to concerns over unnecessary and potentially harmful radiation exposure [11,12]. The American Academy of Orthopedic Surgeons (AAOS), while giving clear guidelines on operative versus nonoperative management of these injuries, has reserved comment on postoperative radiographic evaluation.…”