Role of post-operative X-rays in distal-radius fractures among pediatric patients

Abstract

BACKGROUND

In pediatric age group patients (< 18 years old) treated operatively for distal radius/both bone fractures extending imaging beyond the initial postoperative period -particularly in uncomplicated cases - appears to provide limited additional benefit.

AIM

To determine the necessary number of follow-up X-rays to use resources efficiently.

METHODS

Participants included in this study are pediatric age group patients who were treated operatively for distal radius/both bone fractures and were identified from a prospected collected data from the operating room database between the years 2009 and 2017. The data in the study included patients who had distal radius fractures and underwent fixation surgery (n = 88).

RESULTS

When assessing the difference in the odds of conducting 1 or less X-ray compared to 2 or more X-rays in regard to the type of fixation, the only significant difference is the closed reduction fixation method. Patients who underwent closed reduction method procedure have significantly lower odds of having 2 more X-rays compared to those who didn’t have closed reduction method. Open reduction, internal fixation, and other fixation methods (close reduction and internal fixation, debridement, or epiphysiodesis) have higher odds of having two or more X-rays compared to patients who did not receive these methods; however, these odds are not statistically significant.

CONCLUSION

The findings of this study reveal notable absence of a statistically significant association between the frequency of postoperative X-rays and the outcome of children with distal radius fractures.

Key Words: X-ray; Distal radius fractures; Pediatrics; Orthopedic; Fractures

Core Tip: The study of patients who underwent fixation surgery subsequent to distal radius fracture unveiled several noteworthy findings. To determine the necessary number of follow-up X-rays to use resources efficiently. A total of 88 individuals were included. The findings of this study reveal notable absence of a statistically significant association between the frequency of postoperative X-rays and the outcome of patients with distal radius fractures.

INTRODUCTION

Fractures of the distal radius are the most frequently encountered type of orthopedic injury among children. The yearly rate of these fractures has risen due to children engaging in sports at an earlier age, a rise in body mass index, and a fall in bone mineral density[1]. A fall on an extended arm, leading to axial compression of the limb, or direct impact to the limb, typically causes these fractures. The Salter-Harris classification system is used to categorize physeal (growth plate) fractures of the distal radius. Distal radius fractures that do not involve the growth plate are classified as either incomplete or complete, depending on how much of the bone's cortex is affected. A detailed examination of the upper limb is crucial to identify any additional injuries. Plain PA (posteroanterior) and lateral X-rays of the wrist are generally adequate for diagnosing a distal radius fracture. Decisions on how to treat distal radius fractures depend on the patient's age, the nature of the fracture, and how much the child is expected to grow. Non-operative treatment is commonly preferred due to the high capacity for bone remodeling in this age group. In cases where there is significant angulation or misalignment, closed reduction techniques, possibly along with percutaneous pinning, are indicated. Attempted manipulation of physeal distal radius fractures that could potentially heal improperly is advised against if the patient seeks treatment more than 10 days after the injury, due to a heightened risk of damaging the growth plate[1].

The escalating expenses within the healthcare sector have come under heightened scrutiny, particularly regarding the utilization and expenses associated with imaging services, which have surged at twice the rate of other healthcare technologies[2]. Furthermore, the proliferation of unnecessary follow-up appointments, coupled with prolonged waiting times for imaging procedures, exacerbates the financial burden. In addition to financial considerations, there is growing apprehension regarding the potential adverse effects of ionizing radiation exposure on patients. Medical imaging constitutes the primary source of ionizing radiation exposure for the United States population[3]. While the exact consequences of low-level radiation exposure remain somewhat uncertain, researchers argue that the risk of cancer[4] and cardiovascular[5] ailments correlates with radiation dosage. Moreover, radiographs performed in operating rooms (ORs) pose radiation exposure risks to both patients and hospital personnel.

According to a study conducted in Eastern province, Saudi Arabia, which showed unexpected and concerning results, indicating a noteworthy link between radiation exposure levels in various hospitals, especially related to X-ray and computed tomography scan procedures, with a significant association observed (P < 0.01). Although most hospitals are equipped with lead aprons and thyroid shields for radiation protection, approximately half do not provide lead glasses and lead shields, highlighting a deficiency in critical safety equipment. Additionally, the use of radiation dosimeters is surprisingly low, with only 57.7% and 68.9% adherence rates, underlining a gap in protective measures, which only raises further concerns regarding safety of physicians as well[6].

Therefore, it is imperative to reserve imaging studies for instances where they are clinically warranted to minimize exposure risks. Hence, the excessive utilization of imaging services warrants particular attention and scrutiny. A study conducted in 2010, in Turkey, encompassing 40 cases of forearm fractures treated with open reduction and plate internal fixation, underscored the pivotal role of routine postoperative X-rays in assessing rotational function for such fractures[7]. Conversely, a study in 2015 concluded in Jazan, Saudi Aabia, showed that postoperative radiography, particularly during the initial visit, is primarily instrumental in identifying radiographic changes, including loss of reduction, hardware failure, and hardware migration[8]. These findings suggest a nuanced approach to the timing and necessity of postoperative X-rays.

These conflicting findings underscore the necessity for a comprehensive review of existing literature and real-life clinical practices to elucidate the role of postoperative X-rays in distal radius fractures among pediatric patients. Such insights are crucial for optimizing patient care, minimizing unnecessary radiation exposure, and streamlining healthcare costs. Our aim is To evaluate post-treatment X-rays’ effectiveness in patients with distal radius fractures. This study seeks to determine the necessary number of follow-up X-rays to use resources efficiently. With the high incidence of distal radius fracture among children, it is important to revise the clinical practice done routinely following intervention with consideration of the exposure to ionizing radiation, cost, convenience, and availability of X-rays.

MATERIALS AND METHODS

Setting

This study was conducted at King Fahad Hospital of the University in Al Khobar using the hospital’s electronic record system and the OR database.

Subject participants

Pediatric patients treated operatively at King Fahad Hospital of the University for distal radius fractures were identified from prospectively collected data in the OR database between 2009 and 2017. For patients meeting the criteria, their post-operative notes and follow-up visit notes were reviewed to extract relevant information.

Inclusion criteria

Inclusion criteria including: (1) Pediatric age group (< 18 years old); (2) Treatment period from 2009 to 2017; and (3) Complete follow-up data and no missing information.

Exclusion criteria

Exclusion criteria including: (1) Patients not meeting the inclusion criteria; (2) Missing information in the system; and (3) Sampling technique and sample size all applicable records meeting the inclusion criteria were included in the study, resulting in a sample size of 88 records from 2009 to 2017.

Variables independent variables

Demographics: Age, gender, date of admission. Fracture-related information: Site of the fracture, type of fixation, complications, changes in the management plan, and whether a second operation was required. A change in the management plan was defined as any deviation from the anticipated post-surgical pathway or treatment strategy. This included additional intraoperative or post-operative imaging requests, further surgical procedures, and adjustments in the schedule of follow-up visits.

Dependent variable

The number of post-operative X-rays performed on each patient.

Materials

A data collection sheet was developed, listing patients obtained from the OR database for pediatric distal radius fractures between 2009 and 2017. Data for all relevant variables were extracted from the electronic medical records and entered into the sheet.

Procedure

Following Institutional Review Board approval, a list of cases involving pediatric distal radius fractures from 2009 to 2017 was obtained from the OR records. Data were collected from medical records at King Fahad University Hospital in the Eastern Province of Saudi Arabia. The data were organized, coded, and imported into an Excel spreadsheet for analysis using the SPSS.

Statistical analysis

Frequencies and percentages were calculated to summarize the study variables. The Kruskal-Wallis H test and Mann-Whitney U test were used to evaluate the bivariate association between the study variables and the average number of X-rays performed per patient. A significance threshold of 0.05 was applied, and all analyses were conducted using SPSS software version 27 (IBM Corp, 2017). Crude odds ratios and their corresponding 95% confidence intervals were also determined.

RESULTS

Patient characteristics

The data in the study included patients who have had distal radius fracture and underwent fixation surgery (n = 88). The majority of patients in the study were males (n = 77, 87.5%). The kind of fracture in the study appears to be more popular in the age group 12 to 14 (41%). Most fractures occurred within the diaphysis of the radius bone (n = 46, 52.3%). Furthermore, most patients underwent closed reduction fixation (n = 65, 73.9%), followed by K-wire fixation (n = 58, 65.9%), while close reduction and internal fixation (CRIF), open reduction and internal fixation, debridement, were minimally utilized. Table 1 illustrates patient characteristics. Most patients experienced no complications (n = 86, 97.7%), and almost all patients required no change in the management plan (n = 80, 90.9%). Finally, only 5% of the patients required a second operation (Table 1).

Table 1 Descriptive statistics of study data.

Variable	Group	Frequency (%)
Gender	Male	77 (87.5)
	Female	11 (12.5)
Age (arbitrary classifications)	3-5 years old	17 (19.3)
	6-8 years old	16 (18.2)
	9-11 years old	18 (20.5)
	12-14 years old	36 (40.9)
Site of fracture	Epiphyseal	15 (17.0)
	Metaphyseal	27 (30.7)
	Diaphyseal	46 (52.3)
Type of fixation/surgery	Closed reduction	65 (73.9)
	Open reduction	12 (13.6)
	Internal fixation	11 (12.5)
	CRIF	1 (1.1)
	ORIF	1 (1.1)
	Debridement	1 (1.1)
	Epiphysiodesis	1 (1.1)
	One K wire fixation	58 (65.9)
	Two K wire fixation	13 (14.8)
	TENS	11 (12.5)
Complications	Yes	2 (2.3)
	No	86 (97.7)
Change in management plan	Yes	8 (9.1)
	No	80 (90.9)
Second operation	Yes	4 (4.5)
	No	84 (95.5)

CRIF: Close reduction and internal fixation; TENS: Titanium elastic nailing system; ORIF: Open reduction and internal fixation.

The few patients requiring a change in their management plan (n = 8, 9.1%) had various reasons. Some transitioned from cast to surgical intervention following a second X-ray, revealing a displaced greenstick fracture with angulation. Others were prescribed oral antibiotics with outpatient department follow-up, while some had scheduled follow-up appointments in another hospital. In cases where initial closed reduction in the emergency room was unsuccessful, patients were admitted under general anesthesia. Additionally, after a patient fell again, the cast was replaced. Furthermore, modifications were made to the casting, and an incision was performed over the radial K-wire for certain patients. Finally, some patients were discharged with a transition to a full cast with a back slab casting. All patients received X-rays at admission, intraoperatively, and post-operation. In addition, the vast majority of patients required an X-ray at 1-2 weeks postoperative (n = 54, 61.4%), followed by an X-ray at 3-4 weeks postoperative (n = 40, 45.5%). Some patients extended follow-up X-rays for as long as 3-4 years postoperative. Tow patient had complications inform of fracture displacement that were diagnosed after taking the post-operative X-rays and they underwent revision procedures. Tables 2 and 3 illustrate frequency of follow up X-rays.

Table 2 Postoperative X-ray follow-up intervals and frequencies.

X-ray post op	Frequency (%)
1-2 weeks	54 (61.4)
3-4 weeks	40 (45.5)
5-6 weeks	14 (15.9)
7-8 weeks	19 (21.6)
9-10 weeks	4 (4.5)
11-12 weeks	4 (4.5)
13-14 weeks	4 (4.5)
4 months	3 (3.4)
5 months	6 (6.8)
6 months	2 (2.3)
7 months	1 (1.1)
8 months	2 (2.3)
9 months	1 (1.1)
10 months	2 (2.3)
11 months	1 (1.1)
1 year	5 (5.7)
1 year and a half	1 (1.1)
2 years	2 (2.3)
3-4 years	1 (1.1)

Table 3 Frequency of second operation follow-up X-ray.

Second operation X-ray	Frequency (%)
1-2 weeks	2 (50)
3-4 weeks	2 (50)
6 weeks	2 (50)
9 weeks	2 (50)
3 months	1 (25)
9 months	1 (25)

Analysis of the related factors

None of the study variables appear to be significantly associated with the number of X-rays conducted on patients, using the Mann-Whitney U test and Kruskall-Wallis H test. Table 4 illustrates the influence of the number of X-rays on the study variables. Table 5 show that regardless of the type of fixation, the number of X-rays done to the patients does not differ significantly between the different types of fixations used. Tables 6 and 7 shows the odds ratio of variables influencing the number of X-rays done to each patient (≤ 1 X-ray or ≥ 2 X-rays) after the mandatory post op X-ray. The odds of having 2 or more X-rays when the patient is a male is almost 3 times higher than females, however, this difference is not significant (OR males = 2.897, P = 0.112). In addition, patients between 9 years to 11 years old undergo 2 or more X-rays three times higher than their younger counter parts aged 3 years to 5 years old. This difference, however, is not statistically significant (OR 9-11 years old = 3.111, P = 0.129). Figure 1 describe the types of fixations in the study.

Figure 1 Types of fixations in the study. TENS: Titanium elastic nailing system; ORIF: Open reduction and internal fixation; CK: Close k- wiring.

Table 4 Bivariate analysis to assess the influence of the number of X-rays on the study variables.

Variable	Frequency (%)	Total X-rays (median) (IQR)	Test (P value)
Gender	-	-	Mann-Whitney U = 348.500 (0.328)
Male	77 (87.5)	2.00 (1)
Female	11 (12.5)	1.00 (3)
Age			Kruskal-Wallis H = 0.378 (0.223)
3-5 years old	17 (19.3)	2.00 (2)
6-8 years old	16 (18.2)	2.00 (1)
9-11 years old	18 (20.5)	2.00 (2)
12-14 years old	36 (40.9)	2.00 (2)
Site of fracture			Kruskal-Wallis H = 0.201 (0.905)
Epiphyseal	15 (17.0)	2.00 (1)
Metaphyseal	27 (30.7)	2.00 (1)
Diaphyseal	46 (52.3)	2.00 (2)
Complications			Mann-Whitney U = 75.00 (0.774)
Yes	2 (2.3)	1.50 (0)
No	86 (97.7)	2.00 (1)
Change in management plan			Mann-Whitney U = 307.00 (0.845)
Yes	8 (9.1)	2.00 (3)
No	80 (90.9)	2.00 (1)
Second operation			Mann-Whitney U = 148.500 (0.706)
Yes	4 (4.5)	1.50 (3)
No	84 (95.5)	2.00 (1)

IQR: Interquartile range.

Table 5 Bivariate analysis to assess the association between the number of X-rays and the type of fixation.

Type of fixation	Frequency (%)	Total X-rays Median (IQR)	Mann-Whitney U test (P value)
Closed reduction	65 (73.9)	2.00 (1)	584.00 (0.108)
Open reduction	12 (13.6)	2.00 (1)	317.50 (0.082)
Internal fixation	11 (12.5)	2.00 (1)	312.00 (0.146)
ORIF	4 (4.5)	1.00 (2)	110.00 (0.261)
One K wire fixation	58 (65.9)	2.00 (1)	778.00 (0.403)
Two K wire fixation	13 (14.8)	2.00 (2)	431.00 (0.492)
TENS	11 (12.5)	2.00 (4)	387.00 (0.634)
Other1	3 (3.4)	3.00 (0)	95.00 (0.481)

¹Close reduction and internal fixation, debridement, epiphysiodesis.

TENS: Titanium elastic nailing system; ORIF: Open reduction and internal fixation; IQR: Interquartile range.

Table 6 Odds ratio to compare the variables that significantly influence the number of X-rays (≤ 1 X-ray or ≥ 2 X-rays).

Variables	OR1	95%CI
Gender
Female	1	-
Male	2.897 (0.112)	0.780-10.758
Age
3-5 years old	1	-
6-8 years old	1.143 (0.849)	0.290-4.507
9-11 years old	3.111 (0.129)	0.720-13.443
12-14 years old	0.993 (0.991)	0.313-3.155
Site of fracture
Epiphyseal	1	-
Metaphyseal	1.273 (0.710)	0.357-4.542
Diaphyseal	1.361 (.607)	0.421, 4.405
Complications
No	1	-
Yes	0.686 (0.793)	0.042-11.342
Change in management plan
No	1	-
Yes	1.170 (0.837)	0.261-5.239
Second operation
No	1	-
Yes	0.680 (0.707)	0.091-5.064

¹The constant in the outcome variable is ≤ 1 X-ray done after post op compared to ≥ 2 X-rays.

OR: Odds ratio; CI: Confidence interval.

Table 7 Odds ratio to compare the type of fixation that significantly influence the number of X-rays (≤ 1 X-ray or ≥ 2 X-rays).

Type of fixation	OR1	95%CI
Closed reduction	0.305 (0.035)	0.101-0.919
Open reduction	4.048 (0.084)	0.830-19.731
Internal fixation	3.558 (0.119)	0.721-17.568
ORIF	0.680 (0.707)	0.091-5.064
K wire fixation	0.615 (0.300)	0.246-1.542
2 K wire fixation	1.674 (0.424)	0.473-5.924
TENS	1.244 (0.743)	0.336-4.609
Other2	3.723 (0.240)	0.416-33.308

¹The constant in the outcome variable is ≤ 1 X-ray done after post op compared to ≥ 2 X-rays.

²Other: Close reduction and internal fixation, debridement, or close k- wiring.

OR: Odds ratio; CI: Confidence interval; TENS: Titanium elastic nailing system; ORIF: Open reduction and internal fixation.

Surprisingly, patients with reported complications and patients requiring a second operation have lower number of X-rays compared to those without complications or those who do not require a second operation, this difference, although important, is not significant. Finally, there appears to be no difference in the number of X-rays according to the site of fracture, nor the change in the management plan. When assessing the difference in the odds of conducting 1 or less X-ray compared to 2 or more X-rays in regard to the type of fixation, the only significant difference is the closed reduction fixation method. Patients who underwent closed reduction method procedure have significantly lower odds of having 2 more X-rays compared to those who didn’t have closed reduction method (OR closed reduction = 0.305, P = 0.035). open reduction, internal fixation, and other fixation methods (CRIF, debridement, epiphysiodesis, or close k-wire insertion) have higher odds of having two or more X-rays compared to patients who did not receive these methods; however, these odds are not statistically significant.

DISCUSSION

The study of patients who underwent fixation surgery subsequent to distal radius fracture unveiled several noteworthy findings. Out of the 88 individuals scrutinized, a majority were male, comprising 87.5% of the total sample. Remarkably, individuals aged 12 to 14 seemed more prone to this specific fracture type, constituting a substantial 41% of cases observed. Most fractures were concentrated within the diaphysis of the radius bone. Closed reduction fixation stood out as the prevailing surgical approach, closely followed by K-wire fixation, while other methods like CRIF and open reduction and internal fixation were comparatively less utilized. Incidences of complications were rare, with only 9.1% of patients necessitating a modification in their management plan, often due to factors like displaced fractures or postoperative complications. Moreover, a minority of patients required a subsequent operation. X-rays formed an integral part of patient care, with the majority undergoing postoperative imaging at 1-2 weeks and 3-4 weeks, with some extending up to 3-4 years postoperatively. Intriguingly, the study unearthed no significant correlation between patient demographics, fracture type, or surgical approach with the frequency of X-rays administered. Furthermore, regardless of the method of fixation employed, there was no noticeable discrepancy in the number of X-rays administered to patients. These findings serve to deepen our comprehension of postoperative care and management tactics for distal radius fractures, emphasizing the efficacy and uniformity of current practices within this medical realm.

The study findings illuminate crucial aspects of managing distal radius fractures. One notable finding is the absence of a clear link between study variables and the frequency of X-rays conducted on patients, regardless of the type of fixation employed. These results stand in contrast to one study, which identified a subset of patients necessitating extra postoperative imaging, resulting in adjustments to treatment plans and, in some instances, revision surgery[9]. Similarly, another study advocated for routine postoperative X-rays but found that these images did not impact treatment decisions or patient outcomes[10]. Such disparities underscore the intricacies of clinical decision-making and the diversity in imaging protocols across different healthcare contexts.

Furthermore, the study highlights the overall low incidence of complications and the limited need for altering management strategies among patients undergoing repair surgery for distal radius fractures. Only a small fraction of patients required subsequent procedures, with reasons ranging from the necessity for surgical intervention after further evaluation to modifications in immobilization techniques. This finding aligns with another research that emphasized the constrained clinical value of routine postoperative radiographs following hardware removal in lower extremity fractures[11]. However, it contrasts with another study, which pointed out issues regarding the quality of postoperative X-rays in the realm of total hip arthroplasty, casting doubt on the reliability of imaging methods in diverse orthopedic procedures[12].

Current guidelines on postoperative imaging in pediatric fractures emphasize a patient-specific approach, balancing the need for imaging against potential risks and costs. For example, the American Academy of Orthopaedic Surgeons suggests postoperative radiographs primarily when there are clinical indications such as suspected complications or persistent pain. The findings of this study underscore the potential to streamline imaging protocols, particularly in uncomplicated cases, aligning with broader efforts to reduce healthcare costs and minimize radiation exposure in pediatric populations. This recommendation is supported by research that demonstrates the negligible impact of routine imaging on treatment plans or patient outcomes in similar clinical scenarios[13-16].

Additionally, prior studies highlight conflicting evidence regarding the frequency and utility of postoperative X-rays, with some advocating for routine imaging to monitor healing while others emphasize its limited clinical value. For example, research by[17,18] found that routine X-rays often failed to alter management decisions, raising questions about their necessity in standard practice. Conversely, a subset of literature[19-23], identifies scenarios where additional imaging helped identify complications early, emphasizing the importance of individualizing imaging strategies based on patient risk factors. Reconciling these perspectives would strengthen the evidence base and help define clearer guidelines for pediatric distal radius fracture care.

The timing and frequency of postoperative X-rays, as highlighted in this study, remain a critical area for future exploration. The current practice of performing imaging at 1-2 weeks and 3-4 weeks post-surgery aligns with standard protocols for monitoring healing and identifying early complications[24-26]. However, extending imaging beyond the initial postoperative period - particularly in uncomplicated cases - appears to provide limited additional benefit. Studies like recommend restricting routine imaging to high-risk cases, such as those involving complex fractures or postoperative concerns, to optimize resource utilization without compromising patient outcomes[11]. This approach could be further refined through risk stratification models that consider factors such as fracture severity, patient age, and surgical technique.

In summary, this study contributes to the understanding of distal radius fracture management by emphasizing the limited role of repetitive postoperative X-rays. While the findings support current efforts to reduce unnecessary imaging, further research is needed to develop evidence-based protocols that balance clinical needs with resource efficiency. Incorporating these insights into practice would enhance patient care, reduce healthcare burdens, and align with evolving guidelines in pediatric orthopedic management.

CONCLUSION

The findings of this study reveal notable absence of a statistically significant association between the frequency of postoperative X-rays and the outcome of patients with distal radius fractures. This challenges the current assumption regarding the necessity of routine postoperative radiographic assessments in pediatrics orthopedic patients presenting with distal radius fractures.

ACKNOWLEDGEMENTS

We would like to extend our sincere appreciation to Dr. Arwa Alomran for her invaluable assistance in data analysis and data cleaning.