Routine imaging after operatively repaired distal radius and scaphoid fractures: a survey of hand surgeons.

Imaging contributes substantially to the rising cost of health care.1 Among surgical specialists, orthopaedic surgeons order a particularly high volume of imaging. Radiographic series are regularly taken during the initial evaluation of a patient, during preoperative planning, while the operation is under way, immediately after the operation, and at intervals throughout postoperative follow-up. In addition to the financial burden, imaging is associated with patient and staff time and exposure to radiation. Several studies have recently been conducted based on a common premise: All routine postoperative radiography after orthopaedic procedures should have clinical utility that can be clearly demonstrated. Such studies have investigated immediate postoperative radiography (in the post-anesthesia care unit [PACU])2 3 and postoperative follow-up radiography (in the outpatient clinic).4 5 6 Such studies have been conducted in spine,2 6 total joint arthroplasty,3 4 and orthopaedic trauma.5 These studies have all drawn similar conclusions: They find little support for routine postoperative radiography, and they recommend that postoperative radiography be minimized and/or used only for patients with signs or symptoms of concern for an abnormal postoperative course. In the study regarding follow-up imaging, Ghattas et al studied follow-up imaging in the postoperative management of fractures. 5 They examined the radiographs of 200 consecutive patients taken at the initial postoperative visit after operative management of an array of fractures throughout the body. Fifteen (7.5%) of 200 fractures in 171 patients had a clinical indication for a radiograph because of an abnormal physical examination finding or history of additional trauma. Three (1.5%) of these fractures had a deviation from standard postoperative care; this deviation was a change in postoperative care on the basis of the patient history and physical examination rather than radiographs. The authors found that for only one patient was a change visible between the PACU radiograph and the postoperative follow-up radiograph; yet, even for this patient, there was no resulting change in clinical management. The authors concluded that routine postoperative imaging at the initial visit after operative management of fractures has low clinical utility and could be discontinued. Similarly, Chaudhry et al studied post-splinting radiographs in minimally displaced fractures and found that post-splinting radiographs of minimally displaced or nondisplaced fractures that do not undergo manipulation before/during immobilization do not provide helpful information but do lead to increased health care costs, radiation exposure, and emergency room waits.7 They concluded that routine performance of post-splinting radiography in these cases should be discouraged. Despite the significance of routine postoperative radiography after hand and upper-extremity procedures in terms of cost, time, and radiation exposure, and despite the controversy regarding the utility of routine radiography raised by studies such as those of Ghattas et al and Chaudhry et al, no authors have characterized current imaging practices, compared those practices with the available evidence (e.g., Ghattas et al), or worked toward establishing a standard of care. This study identifies current postoperative imaging practices among a sample of United States hand and upper-extremity surgeons with respect to two common procedures in hand and upper-extremity surgery: operative repair of distal radius fractures and operative repair of scaphoid fractures. First, we characterize imaging practices in the PACU. Second, we characterize imaging practices during outpatient postoperative follow-up. Third, we characterize the willingness of respondents to decrease their volume of postoperative imaging to save costs.