Working toward reducing postoperative fracture radiographs: a survey of Canadian surgeons

Orthopedic surgeons frequently rely on radiographs for fracture diagnosis and thereafter for monitoring the progression of fracture healing. When fracture management includes operative fixation with a load-sharing construct in good-quality bone, screening for healing problems or hardware failure with radiographs in the first 6 postoperative weeks may be unnecessary. For fractures treated with anatomic open reduction, compression and rigid internal fixation with a plate and screw construct, primary bone healing is expected.1–3 Investigators who have studied fractures treated in this fashion have expressed an inability to see any meaningful changes on radiographs obtained in the first 6 weeks after operative compression of the fracture.4,5 Evidence from animal models further demonstrates that compression is maintained across the fracture by the plate and screw construct over the course of 6 weeks.2 The implants themselves rarely seem to fail during this period,4–6 and when they do, such failure, whether gradual or catastrophic, does not go undiagnosed owing to associated symptomatology to guide radiograph acquisition.5 Similarly, for fractures treated with locked intramedullary nails where secondary bone healing is expected, in the majority of patients, callus is not visible on radiographs until after 6 weeks.7 Biomechanically, intramedullary nails have high fatigue strength compatible with supporting full weight bearing for well over 6 weeks, even in patients with comminuted fractures.8,9 In clinical cohorts nails do not fail, even with unrestricted activity,8,9,11 over the initial 6 weeks without a significant traumatic event.10 The literature therefore suggests that when fractures in good-quality bone are treated with compression plating and intramedullary nails, routine radiographs obtained in the first 6 weeks postoperatively do not inform the surgeon regarding healing progression and are unlikely to demonstrate or prevent problems with the implants. Omitting these radiographs may provide certain efficiencies for orthopedic surgeons and their patients. It is unclear how frequently these radiographs are currently part of surgical practice. The objective of this study was to describe Canadian orthopedic surgeons’ practice patterns with respect to screening radiographs in the first 6 postoperative weeks.