Enhancing X-Ray Orders by Utilizing Proper Physical Examination and Applying Clinical Guidelines.

Background: Many pediatric injuries can be diagnosed with one radiograph. Because of health care costs and radiation risks, provider prudence while ordering radiographs is crucial. Although clinical guidelines like Ottawa Ankle Rules (OAR) and Ottawa Knee Rules (OKR) exist, the decision to order radiographs often bypasses clinical judgment. The purpose of this study was to conduct a review of the radiographic practices of providers.

Methods: This was a retrospective cohort of 179 pediatric patients with an extremity injury. Detailed chart review was performed on patients regarding demographics, HPI, physical exam, radiographs, and follow-up. Primary outcomes included radiographs and their relationship to the physical examination. Specifically, knee, ankle, and foot complaints were examined in relation to OAR and OKR. Predictor variables included age, sex, ordering provider, and location of presentation.

Results: At least one set of unnecessary radiographs was performed in 139 (86.3%) of 161 patients with documentation of physical examination. Decreased age was significantly associated with outcomes: unnecessary knee and foot radiographs per OAR and OKR, having completely negative radiographs, having unnecessary radiographs performed, and having zero radiographs indicated. Increased age was correlated with an increase in unnecessary radiographs ordered. Neither provider type nor location of triage showed significant outcomes.

Conclusions: There is a significant number of patients that are not receiving a proper screening before radiographic orders. Providers should return to physical examination and the utilization of clinical guidelines to best serve their patients, while understanding some of the ways that age may negatively impact their habits.

Level of evidence: Level III-retrospective diagnostic study.