A Protocol for Selecting Patients with Injured Extremities Who Need X-Rays

To help curb excessive radiography, we developed a protocol for selecting patients with injured extremities who need x-ray examination, and we tested the protocol prospectively in 848 patients to determine its safety and effectiveness. Strict adherence to the protocol would have reduced x-ray usage by 12 per cent for upper extremities and 19 per cent for lower extremities. The actual reductions were 5 per cent and 16 per cent, respectively, since further reductions were limited by patient's demands for x-ray examinations. One fracture in 287 was missed, but the treatment was appropriate and the outcome satisfactory. By eliminating superfluous x-ray procedures, the protocol could reduce charges by $79 million to $139 million nationwide, without compromising quality of care or increasing malpractice liability. Nevertheless, even the best protocol cannot eliminate all negative x-ray studies. These results should serve as a stimulus for judicious use of radiography, but also as a warning to avoid overzealous cost-containment strategies that would reduce x-ray usage to below a safe threshold. (N Engl J Med. 1982; 306:333–9.) THE practice of medicine in the 20th century has grown progressively more dependent on specialized tools that extend the clinician's powers of observation. Diagnostic procedures such as tissue microscopy, biochemical analyses of body fluids, radiography, computerized tomography, and radioimmunoassay offer the benefits of great accuracy and objectivity, but they also bring with them a new burden of responsibility: The clinician must know when to use them. It is imperative that patients be subjected to a test only when the deterrents of cost, inconvenience, and risk are outweighed by the potential value of the test results. The need for diagnostic x-ray . . .