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\begin{document}

\title{Low value Injury Care in the Adult Orthopaedic Trauma Population: A
Systematic Review}



\author[1]{Mélanie Bérubé}%
\author[2]{Lynne Moore}%
\author[3]{Pier-Alexandre Tardif}%
\author[4]{Gregory Berry}%
\author[2]{Étienne Belzile}%
\author[3]{Martin Lesieur}%
\author[3]{Jérôme Paquet}%
\affil[1]{Centre de recherche du CHU de Quebec-Universite Laval}%
\affil[2]{CHU de Québec-Université Laval}%
\affil[3]{CHU de Quebec-Universite Laval}%
\affil[4]{McGill University}%


\vspace{-1em}



  
  \date{May 17, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objectives. Fifteen potentially low value practices in adult orthopaedic
trauma care were previously identified in a scoping review. The aim of
this study was to synthesize the evidence on these practices. Methods.
We searched four databases for systematic reviews, randomized controlled
trials (RCTs), cohort studies and case series that assessed the
effectiveness of selected practices. Methodological quality was
evaluated using the Measurement Tool to Assess Systematic Reviews
version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal
Checklist for Case Series. We evaluated risk of bias with the Cochrane
revised tool for RCTs and the risk of bias in non-randomized studies of
interventions tool for observational studies. We summarized findings
with measures of frequency and association for primary outcomes.
Results. Of the 30,670 records screened, 70 studies were retained. We
identified high-level evidence of lack of effectiveness or harm for
routine initial imaging of ankle injury, orthosis for A0-A3
thoracolumbar burst fracture in patients \textless{} 60 years of age,
cast or splint immobilization for suspected scaphoid fracture negative
on MRI or confirmed fifth metacarpal neck fracture, and routine
follow-up imaging for distal radius and ankles fractures. However,
evidence was mostly based on studies of low methodological quality or
high risk of bias. Conclusion. In this review, we identified clinical
practices in orthopedic injury care which are not supported by current
evidence and whose use may be questioned. In future research we should
measure their frequency, assess practice variations and evaluate root
causes to identify practices that could be targeted for
de-implementation.%
\end{abstract}%



\sloppy


\textbf{Low value Injury Care in the Adult Orthopaedic Trauma
Population: A Systematic Review}

\textbf{Abstract}

\emph{Objectives.} Fifteen potentially low value practices in adult
orthopaedic trauma care were previously identified in a scoping review.
The aim of this study was to synthesize the evidence on these practices.

\emph{Methods.} We searched four databases for systematic reviews,
randomized controlled trials (RCTs), cohort studies and case series that
assessed the effectiveness of selected practices. Methodological quality
was evaluated using the Measurement Tool to Assess Systematic Reviews
version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal
Checklist for Case Series. We evaluated risk of bias with the Cochrane
revised tool for RCTs and the risk of bias in non-randomized studies of
interventions tool for observational studies. We summarized findings
with measures of frequency and association for primary outcomes.

\emph{Results}\textbf{.} Of the 30,670 records screened, 70 studies were
retained. We identified high-level evidence of lack of effectiveness or
harm for routine initial imaging of ankle injury, orthosis for A0-A3
thoracolumbar burst fracture in patients \textless{} 60 years of age,
cast or splint immobilization for suspected scaphoid fracture negative
on MRI or confirmed fifth metacarpal neck fracture, and routine
follow-up imaging for distal radius and ankles fractures. However,
evidence was mostly based on studies of low methodological quality or
high risk of bias.

\emph{\textbf{Conclusion}.} In this review, we identified clinical
practices in orthopedic injury care which are not supported by current
evidence and whose use may be questioned. In future research we should
measure their frequency, assess practice variations and evaluate root
causes to identify practices that could be targeted for
de-implementation.

\emph{Key words.} Low value care, orthopaedics, trauma, imaging,
systematic review

\textbf{Review criteria}

We searched MEDLINE, EMBASE, Epistemonikos and the Cochrane Central
Register of Controlled Trials from inception to April 2020. Pairs of
reviewers independently screened all identified records with titles,
abstracts and full texts using EndNote and Covidence software. We
reported the number of eligible studies according to design, sample
size, methodological quality / risk of bias, and proportions and
measures of association for primary outcomes for each low value
practice.

\textbf{Message for the clinic:}

In this systematic review, we found high-level evidence of lack of
effectiveness or harm for 6 of these practices: routine initial imaging
of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in
patients \textless{} 60 years of age, cast or splint immobilization for
suspected scaphoid fracture negative on MRI or confirmed fifth
metacarpal neck fracture, and routine follow-up imaging for distal
radius and ankles fractures.

\textbf{Introduction}

Close to 90\% of adult trauma patients present with orthopeadic
injury.\textsuperscript{1} These injuries represent the most expensive
nonfatal injury with costs totaling \$456 billion per year in the
US.\textsuperscript{2,3} These high costs are due to multiple radiologic
imaging for initial and follow-up management, consultations and
interventions performed by specialized human resources, and the loss of
productivity associated with treatments.\textsuperscript{4-8}

Alarmingly, up to 30\% of healthcare budgets are estimated to be spent
on low value care.\textsuperscript{9} Low value practices are defined as
``the common use of a particular intervention when the benefits don't
justify the potential harm or cost''.\textsuperscript{10} Organizations
such as Choosing Wisely emit recommendations on clinical practices that
should be questioned.\textsuperscript{11} However, to date, no
recommendations have been made by Choosing Wisely nor by professional
societies regarding low value practices for the adult orthopeadic trauma
population. In a recent scoping review and survey, 15 potentially low
value practices in adult orthopedic trauma care were identified (Table
1); practices were considered low-value if they were identified as such
in at least one observational study and at least 75\% of experts rated
them as clearly or potentially low value.\textsuperscript{12,13} Experts
were 36 clinicians from Canada, the UK, the US and Australia specialized
in trauma care and actively involved in injury research including 8
orthopedic or spine surgeons; the response rate was 92\%. No attempt to
summarize the benefits \& harms of practices was made at this
stage.\textsuperscript{12} Given the high volume of patients
hospitalized following orthopaedic injury annually, reducing low value
practices in this population may free up considerable resources and to
optimize the quality and efficiency of health care services. However, we
need to appraise available evidence for these practices before
recommendations can be made. The aim of this study was therefore to
synthesize evidence on clinical practices in orthopaedic injury care
that were previously identified as potentially low value.

\textbf{Methods}

We conducted this systematic review using rapid review methodology to
``synthesize a large body of evidence in a timely and credible
manner''.\textsuperscript{14-15} We followed the Cochrane Handbook for
Systematic Reviews of Interventions\textsuperscript{16} and the review
is presented according to the Preferred Reporting Items for Systematic
Reviews and Meta-analysis (PRISMA) checklist (Supplementary Digital File
1).\textsuperscript{17} As per recommendations on rapid review
methodology, we limited the review to studies with the highest available
level of evidence and restricted the search to published
literature.\textsuperscript{14,15}

Eligibility Criteria

Eligibility criteria were developed for each clinical practice using
PICO elements (Supplemental Digital File 2) by the steering committee
including orthopaedic surgeons, a spine surgeon, a trauma team leader, a
trauma nurse practitioner, and a trauma care coordinator, all practicing
in level I trauma centers. Post-treatment diagnostic interventions and
consultations originally targeted specific fractures (e.g. isolated
closed Mason-Johnson type 1 radial head/neck fracture, non-displaced and
minimally displaced fractures). However, upon consultation of the
literature that provided information on many other types of fractures,
we decided to expand our inclusion criteria for these practices
(Supplemental Digital File 3). Using rapid review
methodology\textsuperscript{15}, we applied successive inclusion
criteria using recognized levels of evidence based on study type, i.e.
systematic reviews, RCTs, prospective observational, retrospective
observational, and case series. We did not use study quality as an
eligibility criterion because of the low quality of studies overall. No
restrictions on date or language were applied.

Outcomes

Primary and secondary outcomes were identified for each practice by the
project steering committee on consultation with the literature
(Supplemental Digital File 2). Primary outcomes included missed injuries
(e.g. fracture or luxation/subluxation), complications (e.g.
neurological deficits, fracture mal-union or non-union), change in
clinical management (e.g. surgery, change in immobilization status), and
functional recovery measured with validated tools. Secondary outcomes
included pain, quality of life measured using validated tools,
healthcare service utilization, and return to work.

Search Strategy

With the help of an information specialist, we developed search
strategies for each clinical practice. We searched MEDLINE, EMBASE,
Epistemonikos and the Cochrane Central Register of Controlled Trials
from inception to April 2020. We also checked the reference lists of
reviews and retrieved articles for additional studies. Since this rapid
review aimed to synthesize the evidence based on published studies, we
did not search the grey literature. An example of a search strategy for
a specific practice in Medline is presented in the Supplementary Digital
File 4.

Selection Process

We managed all citations with EndNote software. We identified and
removed duplicates using electronic and manual screening. To ensure
reliability in study selection, all reviewers screened multiple series
of 100 titles in rounds until we achieved acceptable
agreement.\textsuperscript{16} Pairs of reviewers (MB, LM; CC, PAT) then
independently screened all identified records with titles, abstracts and
full texts using EndNote and Covidence software.

Data Extraction and Management

The same pairs of reviewers independently extracted data on study year,
setting and design, study population, intervention(s), comparator(s) and
outcome(s). Clinical practices were classified as follows: routine
initial diagnostic interventions, initial consultation or therapeutic
interventions, and routine post-treatment imaging and follow-up
consultations (Table 1). Routine initial and follow-up imaging was
defined as that occurring at pre-defined time points and not based on
clinical indication.

Quality Assessment

Pairs of reviewers (MB, PAT; LM, PAT) critically appraised quality using
the Measurement Tool to Assess Systematic Reviews version 2
(AMSTAR-2)\textsuperscript{18} and the Critical Appraisal Checklist for
Case Series of the Joanna Briggs Institute.\textsuperscript{19} Risk of
bias in original studies was assessed with the Cochrane tool for RCTs
(RoB2)\textsuperscript{20} and the risk of bias in non-randomized
studies of interventions (ROBINS-I) tool\textsuperscript{21} for cohort
studies.

Any disagreements on eligibility, extracted data or quality were
resolved through discussion between reviewers and on consultation with a
senior reviewer when necessary.

Synthesis

We reported the number of eligible studies according to design, sample
size, methodological quality / risk of bias, and proportions and
measures of association for primary outcomes for each practice. We did
not report results for secondary outcomes considering the large number
of retained studies and the fact that results on secondary outcomes led
to the same conclusions. Similarly, we did not conduct meta-analysis or
assess the credibility of evidence because identified studies on the
same practice were either all case series (no measures of association)
or evaluated different outcomes.

\textbf{Results}

The searches identified 39,696 citations, including 9426 duplicates
(Figure 1). A total of 476/546 studies were excluded after the full-text
review (n=34; Supplementary Digital File 5). After final screening, we
included 70 studies\textsuperscript{22-91}, but no data on primary
outcomes were reported in three of these.\textsuperscript{26,67,91}

Study Characteristics According to Categories of Low value Practices

Most studies were based on case series
(n=33)\textsuperscript{22,31,33,34,36,38,41,43-50,56,57,60-64,66,68-72,74,75,7785,89,90}followed
by systematic reviews with or without meta-analysis
(n=12)\textsuperscript{23-25,28,29,39,53,59,67,78,83,86,88,91},
prospective cohorts (n=9)\textsuperscript{30,32,35,37,42,51,54,79,87},
RCTs (n= 9)\textsuperscript{27,55,65,73,80-82,84} and retrospective
cohorts (n=2; Supplemental Digital File 6).\textsuperscript{52,58}

Methodological Quality of the Studies

Studies focusing on initial diagnostic imaging were mostly of low to
moderate quality or had serious to critical risk of bias (Table 2). One
study on preoperative blood tests in ASA grade I patients respected 9/10
cases series quality criteria\textsuperscript{22}, while another met
half of these criteria.\textsuperscript{38} Among studies on initial
consultation and therapeutic interventions (Table 3), those on spine
consultation after a thoracolumbar transverse process fracture had
serious risk of bias. Among studies evaluating immobilization, RCTs had
serious risk of bias or some concerns were identified, while systematic
reviews were of low to critically low quality. Similarly, for
post-treatment imaging and follow-up consultations (Table 4), systematic
reviews were of critically low quality, RCTs had high risk of bias,
retrospective studies had moderate to critical risk of bias and only 17
of 32 case series (n=17/32) met at least 70\% of methodological quality
criteria (Table 4).

Evidence on Initial Diagnostic Interventions

We identified eight systematic reviews (five with meta-analysis) of
prospective studies\textsuperscript{24-26,28,29,53,59,86,91} and seven
prospective studies\textsuperscript{35,37,40,51,54,79,87} evaluating
routine initial imaging (i.e. X-ray or CT). We also identified two case
series\textsuperscript{22,38} evaluating routine pre-operative blood
tests in American Society of Anaesthesiologist (ASA) grade I patients.
Studies reported injuries would have been missed in [?] 2.0\% of patients
who were negative on a validated clinical decision rule for spine, knee
or ankle injury, or had a negative physical exam for pelvic injury
(Table 2).\textsuperscript{25,35,51,86} One prospective study in
patients \textgreater{} 65 years old\textsuperscript{37} reported 2.0\%
(95\% CI 0.1 to 12.0\%) of clinically relevant missed injuries (e.g.
displaced fractures, subluxation) when the National Emergency
X-Radiography Utilization Study (NEXUS) decision rule was used. X-rays
to detect wrist injury in patients negative on a validated clinical
decision rule or physical exam were associated with more divergent
findings with one prospective study reporting 0\% missed injuries
(range: 0 to 11.4)\textsuperscript{54} and another 10\% (range 1.0 to
19.0).\textsuperscript{87} Preoperative blood tests in ASA grade I
patients requiring minor orthopaedic surgery did not lead to changes in
patient management.\textsuperscript{22,38}

Evidence on Initial Consultation and Therapeutic Interventions

We identified three systematic reviews of RCTs (one with
meta-analysis)\textsuperscript{23,39,88}, six
RCTs\textsuperscript{27,55,65,73,80,81}, two retrospective cohort
studies\textsuperscript{30,32} and one economic
evaluation\textsuperscript{67} evaluating consultation with a spine
surgeon for isolated thoracolumbar fracture and immobilization for
thoracolumbar burst fracture, scaphoid fracture or fifth metacarpal neck
fracture (Table 3). Prospective studies\textsuperscript{30,32}identified
no neurological deficit up to 6 months post-injury in patients who were
not evaluated by a spine surgeon in the context of an isolated T1 to L5
transverse process fracture, mostly localized in the lumbar region.
Systematic reviews\textsuperscript{23,88} and
RCTs\textsuperscript{27,73,80} showed either no difference or less
favorable physical functioning in in patients \textless{} 60 years of
age who were immobilized with an orthosis for a A0-A3 thoracolumbar
burst fracture compared to controls. The same was true for patients with
suspected scaphoid fracture immobilized with a cast compared to those
not immobilized based on magnetic resonance imaging (MRI)
findings\textsuperscript{55,65} and for patients with fifth metacarpal
neck fracture immobilized with a cast or a splint compared to those in
which a less restrictive approach was used (i.e.
wrap).\textsuperscript{39,81}

Evidence on Post-Treatment Imaging and Follow-Up Consultations

We identified two systematic reviews of retrospective studies (one with
meta-analysis)\textsuperscript{78,83}, two RCTs\textsuperscript{82,84},
three cohort studies (one prospective)\textsuperscript{42,52,58} and 32
case
series\textsuperscript{31,33,34,36,41,43-50,56,57,60-64,66,68-72,74-77,85,89,90}evaluating
routine post-treatment imaging and follow-up consultations.

Most case series on post-treatment follow-up (Table 4) showed that [?]
5.0\% of patients with a fracture of the clavicle, upper or lower
extremities required a change from non-operative to operative management
or had complications based on routine X-ray findings. However, a few
studies conducted in the context of radius shaft or head and/or neck
fractures as well as metacarpal fractures observed changes in management
for 10\% to 32\% of patients based on such
findings.\textsuperscript{49,64} Two RCTs showed no difference in
functional recovery of patients with routine follow-up imaging or
consultation for distal radius\textsuperscript{82} or
ankle\textsuperscript{84} fracture compared to those with selective
approaches.

\textbf{Discussion}

In this rapid review, designed to synthetize the published evidence on
potentially low value practices in orthopeadic trauma, we found
consistent evidence of lack of effectiveness or harm for the following
practices: routine initial imaging of the spine (\textless{}65 years of
age), pelvis, knee and ankle in patients negative on a validated
clinical decision rules or physical exam; preoperative blood tests in
ASA grade I patients; spine consultation for isolated thoracolumbar
transverse process fracture; immobilization with an orthosis in patients
\textless{}60 years of age with A0-A3 thoracolumbar burst fractures;
immobilization with a cast or splint for suspected scaphoid fracture
negative on MRI or confirmed fifth metacarpal neck fracture; and routine
follow-up X-ray in patients with clavicle, hip, femur, tibia, ankle or
metatarsal fractures.

Studies on initial imaging of the cervical spine, pelvis, knee and
ankle, consistently observed very small proportions of missed fractures
in patients at low risk on validated decision rules. In addition,
performing preoperative blood tests in ASA grade I patients did not lead
to any adjustment in therapies. However, these results were largely
based on systematic reviews of observational studies. Thus, high quality
RCTs may be needed to confirm that these practices are low-value.
Evidence for wrist imaging was less consistent with one study observing
10\% of missed injuries.\textsuperscript{87} However, this evidence was
based on three prospective studies conducted in patients with similar
types of fractures but using different decision
rules.\textsuperscript{40,54,87} This suggests that more rigorous
research is needed to identify the most accurate clinical decision rule
for initial imaging of the wrist.

Studies on initial consultation and therapeutic interventions provided
consistent evidence of low-value care. Lack of spine surgeon
consultation for isolated T1 to L5 transverse process fracture was not
associated with neurological deficit. Importantly, none of the patients
in these studies required either surgery or an orthosis up to 6 months
post-injury, which are two treatments overseen by spine surgeons. Thus,
these patients could potentially be discharged with recommendations for
pain management and return to activities without a spinal surgery
consultation in the presence of sufficient expertise in radiological
interpretation. We found high-level evidence from systematic reviews of
RCTs and RCTs suggesting that orthosis in patients \textless{}60 years
of age with a A0-A3 thoracolumbar burst fracture and no neurological
symptoms is associated either with no benefit or with harm. Orthosis is
often prescribed to improve patient comfort but restricts patients'
movements causing discomfort and compromising sleep, which may explain
why patients with no orthosis had less or equivalent disability.
Similarly, we found high-level evidence from RCTs that immobilization of
the fifth metacarpal neck fractures leads to greater or equivalent
disability while immobilizing suspected scaphoid fractures is associated
with greater disability. Thus, evidence suggests that limiting the
mobility of patients with these injuries is not beneficial and may even
cause harm.

Some inconsistencies in evidence were observed for post-treatment
routine imaging and follow-up consultations. Fractures to the upper
extremities, particularly fractures to the radius shaft and metacarpal
were associated with high rates of immobilization prolongation in two
studies in which routine imaging was
performed.\textsuperscript{46,64}Also, except for the clavicle, high
proportions of conversion to operative management were observed for
upper extremity fractures. However, these findings were based on case
series in which it wasn't always clear whether included patients had no
clinical indication for post-treatment imaging, such as persistent pain.
One RCT conducted in patients with distal radius fractures did not show
a difference in complications or functional recovery in patients with a
reduced imaging approach.\textsuperscript{82} We found consistent
evidence for routine follow-up X-rays and consultations for lower
extremity fractures (i.e., hip, femur, tibia, ankle, metatarsal); these
practices were not associated with important changes in management or
significant differences in complications or functional recovery when
compared to selective use. However, apart from one RCT conducted in
patients with ankle fractures\textsuperscript{84}, these findings were
mainly observed in case series. Globally, these results suggest that the
number of follow-up X-rays should be questioned.

\textbf{Limitations}

This study has some limitations. First, we may have missed important low
value practices that were not identified in the scoping review or
suggested by clinical experts. For example, no practices related to
surgical procedures were identified although significant variability in
orthopedic surgical intensity among trauma centres was reported in a
recent study.\textsuperscript{92} Second, by using a staged approach for
the inclusion of studies with the most rigorous evidence, we may have
missed some relevant studies. However, for practices with associated
systematic reviews or RCTs, we also included studies with a lower level
of evidence that were published more recently. Lastly, studies with a
high level of evidence were not found for all practices and most studies
were of low methodological quality or had a high risk of bias.

\textbf{Conclusions}

We found high-level evidence that the following clinical practices for
orthopeadic injury care should be questioned: routine initial imaging of
ankle injury; orthosis for A0-A3 thoracolumbar burst fracture in
patients \textless{}60 years of age; cast or splint immobilization for
suspected scaphoid fracture negative on MRI or confirmed fifth
metacarpal neck fracture, and routine follow-up imaging for distal
radius and ankles fractures. In future research, we should measure their
frequency, assess practice variations, and evaluate root causes to
identify those for which de-implementation interventions would be
associated with the greatest benefit. If interventions targeting
de-adoption are deemed appropriate, they will need to be developed with
all stakeholders including clinical experts and patient partners to
account for the full complexity of orthopeadic trauma, such as fracture
characteristics, concomitant injuries and patient characteristics
affecting healing. The reduction of low value clinical practices in the
orthopaedic trauma population has the potential to reduce strain on
health care systems, to improve accessibility to services and to
accelerate return to daily life activities following injury.

\textbf{References}

1. American College of Surgeons Committee on Trauma
Leadership.\emph{National trauma Databank 2016 annual report,} 2016.

2. Miller TR, Lestina DC. Patterns in US medical expenditures and
utilization for injury, 1987. \emph{Am J Public Health}1996;86(1):89-93.

3. Center for Disease Control and Prevention. \emph{Cost of injury care}
. 2017.

4. Berwick DM. Avoiding overuse-the next quality frontier.
\emph{Lancet}2017;390(10090):102-4.

5. Berwick DM, Hackbarth AD. Eliminating waste in US health
care.\emph{JAMA} 2012;307(14):1513-6.

6. Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of
medical services around the world. \emph{Lancet} 2017;390(10090):156-68.

7. Saini V, Brownlee S, Elshaug AG, Glasziou P, Heath I. Addressing
overuse and underuse around the world.
\emph{Lancet}2017;390(10090):105-7.

8. Morgan DJ, Dhruva SS, Coon ER, Wright SM, Korenstein D. 2017 Update
on Medical Overuse: A Systematic Review. \emph{JAMA Intern
Med}2018;178(1):110-5.

9. Reilly BM, Evans AT. Much ado about (doing) nothing. \emph{Ann Intern
Med} 2009;150(4):270-1.

10. Chassin MR, Galvin RW. The urgent need to improve health care
quality. Institute of Medicine National Roundtable on Health Care
Quality. \emph{JAMA} 1998;280(11):1000-5.

11. Cassel CK, Guest JA. Choosing wisely: helping physicians and
patients make smart decisions about their care.
\emph{JAMA}2012;307(17):1801-2.

12. Moore L, Lauzier F, Tardif PA, et al. Low-value clinical practices
in injury care: A scoping review and expert consultation survey. \emph{J
Trauma Acute Care Surg} 2019;86(6):983-93.

13. B\selectlanguage{ngerman}érubé M, Moore L, Leduc S, et al. Low-value injury care in the
adult orthopaedic trauma population: a protocol for a rapid
review.\emph{BMJ Open} 2020;10(3):e033453.

14. Tricco AC, Antony J, Zarin W, et al. A scoping review of rapid
review methods. \emph{BMC Med} 2015;13:224.

15. Tricco AC LE, Straus SE. \emph{Rapid Reviews to Strengthen Health
Policy and Systems: A Practical Guide} . Geneva, Switzerland, 2017.
Contract No.: CC BY-NC-SA3.0 IGO.

16. Higgins J TS. \emph{Cochrane Handbook for Systematic Reviews of
Interventions Version 6.} , 2019.

17. Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for
systematic review and meta-analysis protocols (PRISMA-P) 2015
statement.\emph{Syst Rev} 2015;4(1):1.

18. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal
tool for systematic reviews that include randomised or non-randomised
studies of healthcare interventions, or both. \emph{BMJ} 2017;358:j4008.

19. Moola S MZ, Tufanaru C, Aromataris E, et al. Chapter 7: Systematic
reviews of etiology and risk. In: Aromataris E NZ, ed., \emph{Joanna
Briggs Institute Reviewer's Manual: The Joanna Briggs Institute} , 2017.

20. Sterne JAC, Savovi\selectlanguage{polish}ć \selectlanguage{english}J, Page MJ, et al. RoB 2: a revised tool for
assessing risk of bias in randomised trials. \emph{BMJ} 2019;366:l4898.

21. Sterne JA, Hern\selectlanguage{ngerman}án MA, Reeves BC, et al. ROBINS-I: a tool for
assessing risk of bias in non-randomised studies of
interventions.\emph{BMJ} 2016;355:i4919.

22. Alazzawi S, De Rover WB, Leary T, Hallam PJ. Patients undergoing
blood tests before minor/moderate trauma surgery: a retrospective
review. \emph{JRSM Short Rep} 2012;3(6):39.

23. Alcala-Cerra G, Paternina-Caicedo AJ, Diaz-Becerra C,
Moscote-Salazar LR, Fernandes-Joaquim A. Orthosis for thoracolumbar
burst fractures without neurologic deficit: A systematic review of
prospective randomized controlled trials. \emph{J Craniovertebr Junction
Spine} 2014;5(1):25-32.

24. Anderson PA, Muchow RD, Munoz A, Tontz WL, Resnick DK. Clearance of
the asymptomatic cervical spine: a meta-analysis. \emph{J Orthop
Trauma}2010;24(2):100-6.

25. Bachmann LM, Haberzeth S, Steurer J, ter Riet G. The accuracy of the
Ottawa knee rule to rule out knee fractures: a systematic
review.\emph{Ann Intern Med} 2004;140(2):121-4.

26. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of
Ottawa ankle rules to exclude fractures of the ankle and mid-foot:
systematic review. \emph{BMJ} 2003;326(7386):417.

27. Bailey CS, Urquhart JC, Dvorak MF, et al. Orthosis versus no
orthosis for the treatment of thoracolumbar burst fractures without
neurologic injury: a multicenter prospective randomized equivalence
trial. \emph{Spine J} 2014;14(11):2557-64.

28. Barelds I, Krijnen WP, van de Leur JP, van der Schans CP, Goddard
RJ. Diagnostic Accuracy of Clinical Decision Rules to Exclude Fractures
in Acute Ankle Injuries: Systematic Review and Meta-analysis. \emph{J
Emerg Med} 2017;53(3):353-68.

29. Beckenkamp PR, Lin CC, Macaskill P, Michaleff ZA, Maher CG, Moseley
AM. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a
systematic review with meta-analysis. \emph{Br J Sports
Med}2017;51(6):504-10.

30. Boulter JH, Lovasik BP, Baum GR, et al. Implications of Isolated
Transverse Process Fractures: Is Spine Service Consultation
Necessary?\emph{World Neurosurg} 2016;95:285-91.

31. Braakman M, Verburg AD, Oderwald EE. Are routine radiographs during
conservative treatment of fractures of the fourth and fifth metacarpals
useful? \emph{Acta Orthop Belg} 1996;62(3):151-5.

32. Bradley LH, Paullus WC, Howe J, Litofsky NS. Isolated transverse
process fractures: spine service management not needed. \emph{J
Trauma}2008;65(4):832-6; discussion 6.

33. Burton KR, Mellema JJ, Menendez ME, Ring D, Chen NC. The yield of
subsequent radiographs during nonoperative treatment of radial head and
neck fractures. \emph{J Shoulder Elbow Surg} 2016;25(8):1216-22.

34. Chaudhry S, DelSole EM, Egol KA. Post-splinting radiographs of
minimally displaced fractures: good medicine or medicolegal
protection?\emph{J Bone Joint Surg Am} 2012;94(17):e128.

35. Cheung TC, Tank Y, Breederveld RS, Tuinebreijer WE, de Lange-de
Klerk ES, Derksen RJ. Diagnostic accuracy and reproducibility of the
Ottawa Knee Rule vs the Pittsburgh Decision Rule. \emph{Am J Emerg
Med}2013;31(4):641-5.

36. Cooney AD, Campbell AC. Do check X-rays influence the management of
patients who have undergone hip fracture fixation using image
intensifier guidance? \emph{Injury} 2006;37(8):763-7.

37. Denver D, Shetty A, Unwin D. Falls and Implementation of NEXUS in
the Elderly (The FINE Study). \emph{J Emerg Med} 2015;49(3):294-300.

38. Duggan SM, Tillotson L, McCann PA. Routine Laboratory Tests in Adult
Trauma: Are they Necessary? \emph{The Bulletin of the Royal College of
Surgeons of England} 2011;93(7):266-72.

39. Dunn JC, Kusnezov N, Orr JD, Pallis M, Mitchell JS. The Boxer's
Fracture: Splint Immobilization Is Not Necessary.
\emph{Orthopedics}2016;39(3):188-92.

40. Eyler Y, Sever M, Turgut A, et al. The evaluation of the sensitivity
and specificity of wrist examination findings for predicting
fractures.\emph{Am J Emerg Med} 2018;36(3):425-9.

41. Fenoglio AK, Stephens AR, Zhang C, Presson AP, Tyser AR, Kazmers NH.
Evaluating the Utility of Follow-up Radiographs for Isolated Radial Head
Fractures Undergoing Initial Nonoperative Treatment. \emph{J Orthop
Trauma} 2019;33(8):e291-e5.

42. Finger A, Teunis T, Hageman MG, Thornton ER, Neuhaus V, Ring D. Do
patients prefer optional follow-up for simple upper extremity fractures:
A pilot study. \emph{Injury} 2016;47(10):2276-82.

43. Haddad FS, Williams RL, Prendergast CM. The check X-ray: an
unnecessary investigation after hip fracture fixation?
\emph{Injury}1996;27(5):351-2.

44. Halonen LM, Vasara H, Stenroos A, Kosola J. Routine follow-up is
unnecessary after intramedullary fixation of trochanteric femoral
fractures-Analysis of 995 cases. \emph{Injury} 2020;51(6):1343-5.

45. Harish S, Vince AS, Patel AD. Routine radiography following ankle
fracture fixation: a case for limiting its use.
\emph{Injury}1999;30(10):699-701.

46. Heckmann N, Dusch MN, Pannell WC, Bauschard M, Alluri RK,
Sivasundaram L, et al. The Utility of Plain Films for Nonoperative Fifth
Metacarpal Fractures: Are Follow-up Radiographs Necessary? \emph{Hand (N
Y)} 2018;13(6):646-51.

47. Huffaker S, Earp BE, Blazar PE. The value of post-operative
radiographs in clinical management of AO type A distal radius
fractures.\emph{J Hand Surg Eur} 2015;40(8):790-5.

48. Jacxsens M, Schmid J, Zdravkovic V, Jost B, Spross C. Is serial
radiological evaluation of one-part proximal humeral fractures
necessary? \emph{Bone Joint J} 2019;101-B(10):1307-12.

49. Jayaram PR, Bhattacharyya R, Jenkins PJ, Anthony I, Rymaszewski LA.
A new ''virtual'' patient pathway for the management of radial head and
neck fractures. \emph{J Shoulder Elbow Surg} 2014;23(3):297-301.

50. Jennewine B, Fiorino D, Kew M, Byrne A, Yarboro S. Routine
postoperative radiographs after tibia plateau fixation have minimal
impact on patient care. \emph{Injury} 2019;50(11):2093-6.

51. Jenny JY, Boeri C, El Amrani H, Dosch JC, Dupuis M, Moussaoui A, et
al. Should plain X-rays be routinely performed after blunt knee trauma?
A prospective analysis. \emph{J Trauma} 2005;58(6):1179-82.

52. Johnson SP, Chung KC, Zhong L, Sears ED, Waljee JF. Use of
Postoperative Radiographs following Operative Fixation of Distal Radius
Fractures. \emph{Plast Reconstr Surg} 2016;138(6):1255-63.

53. Jonckheer P, Willems T, De Ridder R, et al. Evaluating fracture risk
in acute ankle sprains: Any news since the Ottawa Ankle Rules? A
systematic review. \emph{Eur J Gen Pract} 2016;22(1):31-41.

54. Karaca Y, Turkmen S, Cansu A, et al. A study to develop clinical
decision rules for the use of radiography in wrist trauma: Karadeniz
wrist rules. \emph{Am J Emerg Med} 2016;34(11):2074-8.

55. Kelson T, Davidson R, Baker T. Early MRI versus conventional
management in the detection of occult scaphoid fractures: what does it
really cost? A rural pilot study. \emph{J Med Radiat
Sci}2016;63(1):9-16.

56. Kuorikoski JM, Soderlund TP. Evaluation of a routine follow-up visit
after an internal fixation of proximal femoral fracture.
\emph{Injury}2017;48(2):432-5.

57. Kurup HV, Michael ALR, Beaumont AR. The need for routine
postoperative radiographs in hip fracture fixation: an audit-based
approach. \emph{European Journal of Orthopaedic Surgery \&
Traumatology}2008;18(4):265-7.

58. McDonald MR, Bulka CM, Thakore RV, et al. Ankle radiographs in the
early postoperative period: do they matter? \emph{J Orthop
Trauma}2014;28(9):538-41.

59. Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. Accuracy of
the Canadian C-spine rule and NEXUS to screen for clinically important
cervical spine injury in patients following blunt trauma: a systematic
review. \emph{CMAJ} 2012;184(16):E867-76.

60. Miniaci-Coxhead SL, Martin EA, Ketz JP. Quality and Utility of
Immediate Formal Postoperative Radiographs in Ankle Fractures.\emph{Foot
Ankle Int} 2015;36(10):1196-201.

61. Nagar M, Forrest N, Maceachern CF. Utility of follow-up radiographs
in conservatively managed acute fifth metatarsal fractures. \emph{Foot
(Edinb)} 2014;24(1):17-20.

62. Oehme F, Link BC, Frima H, Schepers T, Rhemrev SJ, Babst R, et al.
Is there a need for standardized postoperative radiographs after
operative treatment of wrist or ankle fractures? \emph{Eur J Trauma
Emerg Surg} 2019;45(6):1039-44.

63. Ovaska MT, Nuutinen T, Madanat R, Makinen TJ, Soderlund T. The role
of outpatient visit after operative treatment of ankle
fractures.\emph{Injury} 2016;47(11):2575-8.

64. Pannell WC, Alluri RK, Sivasundaram L, Heckmann N, Ghiassi A.
Utility of Postoperative Imaging in Radial Shaft Fractures. \emph{Hand
(N Y)} 2016;11(2):184-7.

65. Patel NK, Davies N, Mirza Z, Watson M. Cost and clinical
effectiveness of MRI in occult scaphoid fractures: a randomised
controlled trial. \emph{Emerg Med J} 2013;30(3):202-7.

66. Phelps K, Coleman M, Seymour R, Bosse M. Utility of Routine
Postoperative Radiographs After Fixation of Lower Extremity
Fractures.\emph{J Am Acad Orthop Surg} 2018;26(22):799-808.

67. Piazza M, Sinha S, Agarwal P, et al. Post-operative bracing after
pedicle screw fixation for thoracolumbar burst fractures: A
cost-effectiveness study. \emph{J Clin Neurosci} 2017;45:33-9.

68. Robertson A, Sutherland M, Keating JF. Intramedullary nailing of
tibial fractures: how often are post-operative radiographs
needed?\emph{J R Coll Surg Edinb} 2000;45(4):220-2.

69. Sahin E, Kalem M. Utility of Third-Week Postoperative Radiographs in
the Management of Ankle Fractures. \emph{Foot Ankle
Spec}2018:1938640017751188.

70. Sanchez Morales D, Borade A, Serrano-Riera R, Maniar HH, Sanders RW,
Horwitz DS. Potential Economic Benefits of Limited Clinical and
Radiographic Follow-up After Plate Fixation of Midshaft Clavicle
Fractures. \emph{J Am Acad Orthop Surg} 2019;27(11):405-9.

71. Schuld JC, Volker ML, Anderson SA, Zwank MD. Postsplinting x-rays of
nondisplaced hand, wrist, ankle, and foot fractures are
unnecessary.\emph{Am J Emerg Med} 2016;34(8):1625-6.

72. Segal D, Palmanovich E, Faour A, et al. Routine early post-operative
X-ray following internal fixation of intertrochanteric femoral fractures
is unjustified: a quality improvement study. \emph{J Orthop Surg
Res}2018;13(1):189.

73. Shamji MF, Roffey DM, Young DK, Reindl R, Wai EK. A pilot evaluation
of the role of bracing in stable thoracolumbar burst fractures without
neurological deficit. \emph{J Spinal Disord Tech} 2014;27(7):370-5.

74. Sharma V, Witney-Lagen C, Cullen S, et al. The Role of Early
Post-Operative Radiographs Following Distal Radius Fracture Fixation
with a Volar Locking Plate: Time for Change? \emph{J Hand Surg Asian
Pac} 2019;24(4):435-9.

75. Shubert DJ, Shepet KH, Kerns AF, Bramer MA. Postoperative chest
radiograph after open reduction internal fixation of clavicle fractures:
a necessary practice? \emph{J Shoulder Elbow Surg} 2019;28(5):e131-e6.

76. Shulman BS, Lee JH, Liporace FA, Egol KA. Minimally displaced radial
head/neck fractures (Mason type-I, OTA types 21A2.2 and 21B2.1): are we
''over treating'' our patients? \emph{J Orthop Trauma} 2015;29(2):e31-5.

77. Stone JD, Vaccaro LM, Brabender RC, Hess AV. Utility and cost
analysis of radiographs taken 2 weeks following plate fixation of distal
radius fractures. \emph{J Hand Surg Am} 2015;40(6):1106-9.

78. Teo T, Schaeffer E, Cooper A, Mulpuri K. Do Immediate Postoperative
Radiographs Change Patient Management After Fracture Fixation? A
Systematic Review. \emph{J Orthop Trauma} 2018;32(5):211-5.

79. Tran J, Jeanmonod D, Agresti D, Hamden K, Jeanmonod RK. Prospective
Validation of Modified NEXUS Cervical Spine Injury Criteria in Low-risk
Elderly Fall Patients. \emph{West J Emerg Med} 2016;17(3):252-7.

80. Urquhart JC, Alrehaili OA, Fisher CG, Fleming A, Rasoulinejad P,
Gurr K, et al. Treatment of thoracolumbar burst fractures: extended
follow-up of a randomized clinical trial comparing orthosis versus no
orthosis. \emph{J Neurosurg Spine} 2017;27(1):42-7.

81. van Aaken J, Fusetti C, Luchina S, et al. Fifth metacarpal neck
fractures treated with soft wrap/buddy taping compared to reduction and
casting: results of a prospective, multicenter, randomized
trial.\emph{Arch Orthop Trauma Surg} 2016;136(1):135-42.

82. van Gerven P, El Moumni M, Zuidema WP, et al. Omitting Routine
Radiography of Traumatic Distal Radial Fractures After Initial 2-Week
Follow-up Does Not Affect Outcomes. \emph{J Bone Joint Surg
Am}2019;101(15):1342-50.

83. van Gerven P, Rubinstein SM, Nederpelt C, et al. The value of
radiography in the follow-up of extremity fractures: a systematic
review. \emph{Arch Orthop Trauma Surg} 2018;138(12):1659-69.

84. van Gerven P, van Dongen JM, Rubinstein SM, et al. Reduction of
routine use of radiography in patients with ankle fractures leads to
lower costs and has no impact on clinical outcome: an economic
evaluation. \emph{BMC Health Serv Res} 2020;20(1):893.

85. van Gerven P, Weil NL, Termaat MF, et al. Routine Follow-Up
Radiographs for Ankle Fractures Seldom Add Value to Clinical
Decision-Making: A Retrospective, Observational Study. \emph{J Foot
Ankle Surg} 2018;57(5):957-60.

86. van Trigt J, Schep NWL, Peters RW, Goslings JC, Schepers T, Halm JA.
Routine pelvic X-rays in asymptomatic hemodynamically stable blunt
trauma patients: A meta-analysis. \emph{Injury} 2018;49(11):2024-31.

87. Walenkamp MM, Bentohami A, Slaar A, et al. The Amsterdam wrist
rules: the multicenter prospective derivation and external validation of
a clinical decision rule for the use of radiography in acute wrist
trauma. \emph{BMC Musculoskelet Disord} 2015;16:389.

88. Wallace N, McHugh M, Patel R, Aleem IS. Effects of Bracing on
Clinical and Radiographic Outcomes Following Thoracolumbar Burst
Fractures in Neurologically Intact Patients: A Meta-Analysis of
Randomized Controlled Trials. \emph{JBJS Rev} 2019;7(9):e9.

89. Weil NL, El Moumni M, Rubinstein SM, Krijnen P, Termaat MF, Schipper
IB. Routine follow-up radiographs for distal radius fractures are seldom
clinically substantiated. \emph{Arch Orthop Trauma
Surg}2017;137(9):1187-91.

90. Westerterp M, Emous M, Vermeulen MC, Eerenberg JP, van Geloven AA.
No additional value of routine check X-rays after internal fixation of
hip fractures. \emph{Eur J Trauma Emerg Surg} 2013;39(2):163-5.

91. Paykin G, O'Reilly G, Ackland H, Mitra B. Review article: NEXUS
criteria to rule out cervical spine injury among older patients: A
systematic review. \emph{Emerg Med Australas} 2018;30(4):450-5.

92. Patton MP, Moore L, Farhat I, et al. Inter-hospital variation in
surgical intensity for trauma admissions: A multicentre cohort
study.\emph{Int J Clin Pract} 2020;74(11):e13613.

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