Routine Follow-Up Radiographs for Ankle Fractures Seldom Add Value to Clinical Decision-Making: A Retrospective, Observational Study

Efficacy of post-operative X-rays after operatively treated ankle fractures: What is their role?

OBJECTIVE

The utility of routine post-operative imaging in clinically asymptomatic patients is unclear. We sought to determine how frequently X-rays following operatively treated ankle fractures result in a change in management.

DESIGN

Retrospective cohort study conducted with hospital electronic health record SETTING: Single level 1 trauma center in major urban city.

PATIENTS/PARTICIPANTS

193 patients with operatively treated ankle fractures at our institution between January 2020 and December 2021.

MAIN OUTCOME MEASURES

Patient radiographs were categorized as surveillance X-rays and clinically indicated X-rays. Changes in management were defined as alteration in follow-up, deviation from standard post-operative protocols, or revision surgery. A logistic regression was performed looking at factors predicting whether an X-ray changes management. A cost analysis was also performed looking at the financial implications of asymptomatic surveillance of ankle fractures.

RESULTS

438 post-operative X-rays were found and included in analysis. Of these, 391 were considered surveillance X-rays and 47 clinically indicated. 23 X-rays were determined to have resulted in changes in management (18 clinically indicated, 5 taken in asymptomatic patients). The number of management changing X-rays was significantly higher in the clinically indicated group (p < 0.0001). The only factor associated with whether an X-ray changed management was whether the patient was symptomatic at the visit (p < 0.0001). Asymptomatic surveillance X-rays cost our institution 21,825.62 USD per year.

CONCLUSIONS

Radiographs in clinically asymptomatic patients with operatively managed ankle fractures have a low likelihood of changing management. Such imaging represents costs to the healthcare system, increased time for patients during clinic visits, and radiation exposure. The use of screening radiographic studies remains commonplace because the risk of delayed diagnosis is great, and the goal of any surgeon should be the swift identification of complications in order to minimize patient morbidity. Future surveillance protocols should consider the findings of this and other studies on the use of screening radiographs and strike a careful balance between minimizing unnecessary imaging, maximizing early complication detection, and ensuring a personalized approach towards patient-level factors to optimize care and efficiency for both patient and health system.

LEVEL OF EVIDENCE

Level III.

The value of routine radiographic follow up in the postoperative management of canine medial patellar luxation

OBJECTIVE

To determine the influence of radiographic examination on the recommendations made at the time of planned re-evaluation of dogs after medial patellar luxation (MPL) surgery.

STUDY DESIGN

Retrospective multi-institutional case series.

ANIMALS

Client-owned dogs (N = 825) that underwent MPL surgery.

METHODS

Records of 10 referral institutions were searched for dogs that had been treated surgically for unilateral MPL and underwent a planned follow-up visit, including radiographs. The frequency of, and reasons for, changes in further recovery recommendations were investigated.

RESULTS

Follow up was performed at a median of 6 (range, 4-20) weeks postoperatively. Isolated radiographic abnormalities were identified in 3.3% (27/825) of dogs following MPL surgery and led to a change in recommendations in 3% (13/432) of dogs that were presented without owner or clinician concerns. Lameness, administration of analgesia at follow up, and history of unplanned visits prior to routine re-examination were associated with a change in postoperative plan (P < .001). In the absence of owner and clinician concerns, the odds of having a change in convalescence plans were not different, whether or not isolated radiographic abnormalities were present (P = .641).

CONCLUSION

Routine radiographs at follow up did not influence postoperative management of most dogs after MPL surgery in the absence of abnormalities on clinical history or orthopedic examination.

CLINICAL SIGNIFICANCE

Dogs that were presented for routine follow up after unilateral MPL surgery without owner concerns, lameness, analgesic treatment or a history of unplanned visits, and for which examination by a surgical specialist was unremarkable, were unlikely to benefit from radiographs.

Predicting factors for better outcomes of stable supination external rotation type 2 ankle fractures

PURPOSE

Stable Weber B ankle fractures are treated by a walking boot for 6 weeks and bearing full weight through the boot as tolerated. The aim of the present study was to assess the outcome parameters of this treatment protocol, evaluate the efficacy of using the walking boot, and investigate any possible predicting factors that could affect the outcomes.

METHODS

All the patients with stable Weber B ankle fractures, treated in our hospital between January 2018 and December 2018, were prospectively included to the study. The patients were evaluated clinically, and the patient-reported outcome measures data were collected at the 2 and 6 weeks post-injury. Chi square, Spearman's rho test, independent samples and paired sample t-tests were used for the monovariant analysis.

RESULTS

A total of 128 consecutive patients (aged 52.2 ± 19.1 years) with supination external rotation type 2 fracture were finally included to the study. At the 2 weeks follow-up, the reported outcome measures scores were in moderate levels, but improved significantly at the 6 weeks follow-up (p < 0.0001). Multivariant analysis revealed that the ability to bear full weight without the boot at the 2 weeks after diagnosis was the only variable, which made statistically unique contribution to the foot and ankle disability index score at the 6 weeks (p = 0.005).

CONCLUSION

Conservative treatment using a walking boot with advice to bear full weight of stable ankle Weber B fractures can bring to good functional outcomes. The ability to bear full weight without the aid of the walking boot at 2 weeks after diagnosis was the only significant predicting factor for better outcomes at 6 weeks after diagnosis.

A systematic review of outcome reporting in clinical trials of distal tibia and ankle fractures

Aims

To describe outcome reporting variation and trends in non-pharmacological randomized clinical trials (RCTs) of distal tibia and/or ankle fractures.

Methods

Five electronic databases and three clinical trial registries were searched (January 2000 to February 2022). Trials including patients with distal tibia and/or ankle fractures without concomitant injuries were included. One reviewer conducted all searches, screened titles and abstracts, assessed eligibility, and completed data extraction; a random 10% subset were independently assessed and extracted by a second reviewer at each stage. All extracted outcomes were mapped to a modified version of the International Classification of Functioning, Disability and Health framework. The quality of outcome reporting (reproducibility) was assessed.

Results

Overall, 105 trials (n = 16 to 669 participants) from 27 countries were included. Trials compared surgical interventions (n = 62), post-surgical management options (n = 17), rehabilitative interventions (n = 14), surgical versus non-surgical interventions (n = 6), and pre-surgical management strategies (n = 5). In total, 888 outcome assessments were reported across seven domains: 263 assessed body structure or function (85.7% of trials), 136 activities (68.6% of trials), 34 participation (23.8% of trials), 159 health-related quality of life (61.9% of trials), 247 processes of care (80% of trials), 21 patient experiences (15.2% of trials), and 28 economic impact (8.6% of trials). From these, 337 discrete outcomes were described. Outcome reporting was inconsistent across trials. The quality of reporting varied widely (reproducibility ranged 4.8% patient experience to 100% complications).

Conclusion

Substantial heterogeneity in outcome selection, assessment methods, and reporting quality were described. Despite the large number of outcomes, few are reported across multiple trials. Most outcomes are clinically focused, with little attention to the long-term consequences important to patients. Poor reporting quality reduces confidence in data quality, inhibiting data synthesis by which to inform care decisions. Outcome reporting guidance and standardization, which captures the outcomes that matter to multiple stakeholders, are urgently required. Cite this article: Bone Jt Open 2022;3(10):832–840.

Utility of Post-Splinting Conventional Radiographs in Adult Patients With Ankle Fractures Presenting to the Emergency Department

BACKGROUND

Post-splinting radiographs are often performed in patients with ankle fractures to identify displacement that potentially occurs during splinting. The objective of this study was to investigate the significance of post-splinting conventional radiographs, with an emphasis on stable ankle fractures, not requiring reduction.

METHODS

A retrospective study in which all adult patients presenting with ankle fractures to the emergency department of a level 1 trauma center were included. The primary outcome was frequency of displacement at post-splinting radiographs. Secondary outcome was the rate of successful reduction attempts.

RESULTS

A total of 225 patients were included and the majority had a Supination-External Rotation (SER) type 2 or Weber B ankle fracture. One hundred fifty patients (mainly SER 2 fractures [68%] or Weber B [89%] fractures), were treated with a splint without fracture reduction. Post-splinting radiographs in these patients, as well as in all patients with a Supination-Adduction (SA) type 1 and 2 fractures, did not show loss of alignment.

CONCLUSION

Post-splinting radiographs are probably not necessary in any SA and SER type 2 or Weber A/B ankle fractures without medical clear space widening or need for reduction as no loss of alignment occurred when applying a splint.

LEVEL OF EVIDENCE

IV-Case Series.

An Evaluation of Patient Characteristics Associated With Medical Disposition in the Surgical Treatment of Ankle Fractures

The objective of this investigation was to evaluate patient characteristics associated with medical disposition in treatment of ankle fractures. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was interrogated with data extracted related to the 6 current procedural terminology (CPT) codes available pertaining to ankle fractures: 27766, 27769, 27792, 27814, 27822, and 27823. The primary outcome analysis involved a comparison of patient characteristics and short-term adverse outcomes between those fractures repaired on an inpatient basis versus outpatient basis. A secondary analysis was then performed on patient characteristics and adverse short-term outcomes between those fractures treated on an inpatient basis who were discharged home versus elsewhere. Age (p < .001), race (p < .001), ethnicity (p < .001), body mass index (BMI) (p < .001), estimated probability of mortality (p < .001), estimated probability of morbidity (p < .001), CPT code of fracture designation (p < .001), functional status (p < .001), elective surgery designation (p < .001), American Society of Anesthesiologists class (p < .001), diabetes (p < .001), smoking status (p < .001), dyspnea (p < .001), COPD (p < .001), congestive heart failure (p < .001), hypertension (p < .001), dialysis (p < .001), cancer (p < .001), steroid use (p < .001), blood transfusion history (p < .001), and sepsis/systemic inflammatory response syndrome history (p < .001) were all independently associated with the ankle fracture repair being performed on an inpatient basis on regression analysis. Age (p < .001), race (p = .025), ethnicity (p < .001), BMI (p = .001), CPT code of fracture designation (p < .001), preoperative functional status (p < .001), and American Society of Anesthesiologists class (p < .001) were all independently associated with inpatient ankle fracture repairs being discharged to home following the procedure on regression analysis. The results of this investigation demonstrate that differences in patient demographic characteristics might contribute to medical decision-making as it relates to patient management and discharge disposition in the treatment of ankle fractures.

Low-value injury care in the adult orthopaedic trauma population: A systematic review

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 synthesise the evidence on these practices.

METHODS

We searched four databases for systematic reviews, randomised 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-randomised studies of interventions tool for observational studies. We summarised 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 <60 years of age, cast or splint immobilisation 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 orthopaedic 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.

Virtual clinics in foot and ankle surgery: patient and clinician perceptions

BACKGROUND

The worldwide COVID-19 pandemic has led to the popularisation of 'virtual' clinics. In orthopaedics, little is known about the use of virtual clinics within foot and ankle surgery, specifically.

METHODS

A cross-sectional observation study of patients and clinicians in response to virtual clinics in foot and ankle surgery. Patients seen in a virtual clinic were contacted by telephone from two weeks after their consultation and asked to complete a 12-point questionnaire. Demographic information was also collected. Clinicians in foot and ankle completed a 10-point questionnaire.

RESULTS

One hundred patient responses were collected. Patient satisfaction with virtual clinics was positive, with 65% of respondents reporting they were very happy (Likert scale rating 5). More than 90% of patients felt they received enough information, felt involved, felt the virtual clinic was helpful and knew who to contact if there was a problem. However, 79% would still prefer a face-to-face consultation, and 22% would have preferred a video consultation. Clinician responses were more cautious, with 60% stating they were neither happy nor unhappy (Likert scale rating 3). Virtual clinics may be faster for the clinician.

CONCLUSIONS

Virtual clinics may be more convenient for patients, with high satisfaction levels reported, but represent significant clinical challenges for foot and ankle surgeons. Elements of virtual clinics may persist post pandemic, particularly in routine follow-up. Virtual clinics are not appropriate for new patient referrals.

Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures

Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed.

The acute management of ankle fractures (Augment) study: A prospective trainee led national collaborative audit of the Boast 12 guidelines

BACKGROUND

Ankle fractures are one of the most common fractures in adults aged 20-65 years. The British Orthopaedic Association (BOA) and British Orthopaedic Foot and Ankle Society (BOFAS) jointly produced Standards for Trauma (BOAST) BOAST 12, with the aim of reducing morbidity by standardising care of these injuries. The primary aim of the AUGMENT study was to determine the extent and clinical effect of variation from BOAST 12.

METHODS

AUGMENT was a multi-centre prospective trainee led audit of consecutive patients presenting with an ankle fracture within a four-week period. Data were collected on patient demographics, comorbidities, management and 12-week outcome. The BOAST 12 standards were divided into four subgroups; documentation, imaging, management and follow-up. Percentage compliance with each subgroup was analysed. A multivariate logistic regression analysis was used to determine impact of overall compliance on likelihood of discharge in follow-up period.

FINDINGS

971 patients were included across 52 sites. The overall rate of BOAST 12 compliance was 41.7%. Variations in practice were observed in clinical documentation, especially of neurovascular status, (40.7%) and VTE assessment (61.5%). Patient management compliance with all 16 of the BOAST 12 standards was associated with a higher rate of discharge during the 12-week follow-up period (p = 0.005).

CONCLUSION

AUGMENT has demonstrated that the management of ankle fractures is variable across the UK. Over half of patients had aspects of their care that were not BOAST 12 compliant. When compliance was observed, it was associated with earlier discharge from orthopaedic care.

Influence of radiographic examination findings on recommendations made during routine clinical re-evaluation of dogs with uncomplicated tibial plateau leveling osteotomy

OBJECTIVE

To determine the influence of follow-up radiographic examination on recommendations made during routine clinical re-evaluation of dogs that had undergone uncomplicated tibial plateau leveling osteotomy (TPLO).

STUDY DESIGN

Retrospective multi-institutional case series.

ANIMALS

Client-owned dogs (N = 1010) that underwent uncomplicated TPLO.

METHODS

Records from 11 institutions were searched for dogs that had been treated with unilateral TPLO and had no history of postoperative complications before their routine follow-up examination. The frequency of change in further clinical recommendations resulting from client- or clinician-voiced concerns or radiographic abnormalities was investigated.

RESULTS

Follow-up evaluation was performed at a median of 6 (range, 4-15) weeks after TPLO. Radiographic examination findings contributed to a change in recommendations in 4.15% (38/915) of dogs presented without client concerns and without abnormalities at orthopedic examination. Abnormal radiographic findings alone influenced the management of 3.76% (38/1010) of dogs. An association was detected between clinical features and radiological findings leading to a change in recommendations (P < .0001). Administration of analgesia at the time of follow-up was associated with radiographic abnormalities (P = .017) and change in postoperative plans (P = .0007).

CONCLUSION

Radiographic examination findings at follow-up did not influence the management of most dogs with uncomplicated TPLO.

CLINICAL SIGNIFICANCE

Radiographic examination findings are unlikely to influence the treatment of dogs that seem to be recovering uneventfully from an uncomplicated TPLO without concerns from clients, analgesia, or abnormal findings on thorough orthopedic examination by a surgical specialist, at the time of the planned clinical re-evaluation.

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

BACKGROUND

To evaluate the cost-effectiveness of a reduction in the number of routine radiographs in the follow-up of patients with ankle fractures.

METHODS

We performed an economic evaluation alongside the multicentre, randomised WARRIOR trial. Participants were randomised to a reduced imaging follow-up protocol (i.e. radiographs at week 6 and 12 follow-up obtained on clinical indication) or usual care (i.e. routine radiography at weeks 6 and 12). The Olerud & Molander Ankle Score (OMAS) was used to assess ankle function and the EQ-5D-3L was used to estimate Quality-Adjusted Life Years (QALYs). Costs and resource use were assessed using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation was used for missing data, and data were analysed using seemingly unrelated regression analysis and bootstrapping.

RESULTS

In total, 246 patients had data available for analysis (reduced imaging = 118; usual care = 128). Fewer radiographs were obtained in the reduced imaging group (median = 4) compared with the usual-care group (median = 5). Functional outcome was comparable in both groups. The difference in QALYs was - 0.008 (95% CI:-0.06 to 0.04) and the difference in OMAS was 0.73 (95% CI:-5.29 to 6.76). Imaging costs were lower in the reduced imaging group (-€48; 95% CI:- €72 to -€25). All other cost categories did not statistically differ between the groups. The probability of the reduced imaging protocol being cost-effectiveness was 0.45 at a wiliness-to-pay of €20,000 per QALY.

CONCLUSIONS

Reducing the number of routine follow-up radiographs has a low probability of being cost-effective compared with usual care. Functional outcome, health-related quality of life and societal costs were comparable in both groups, whereas imaging costs were marginally lower in the reduced imaging group. Given this, adherence to a reduced imaging follow-up protocol for those with routine ankle fractures can be followed without sacrificing quality of care, and may result in reduced costs.

TRIAL REGISTRATION

The trial was registered on 26-05-2014 in the Netherlands Trial Registry, with reference number NL4477 ( www.trialregister.nl/trial/4477 ).

Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-up Does Not Affect Outcomes: The WARRIOR Trial: A Multicenter Randomized Controlled Trial

BACKGROUND

The clinical consequences of routine follow-up radiographs for patients with ankle fracture are unclear, and their usefulness is disputed. The purpose of the present study was to determine if routine radiographs made at weeks 6 and 12 can be omitted without compromising clinical outcomes.

METHODS

This multicenter randomized controlled trial with a noninferiority design included 246 patients with an ankle fracture, 153 (62%) of whom received operative treatment. At 6 and 12 weeks of follow-up, patients in the routine-care group (n = 128) received routine radiographs whereas patients in the reduced-imaging group (n = 118) did not. The primary outcome was the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle questionnaire, health-related quality of life (HRQoL) as measured with the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) and Short Form-36 (SF-36), complications, pain, health perception, self-perceived recovery, the number of radiographs, and the indications for radiographs to be made. The outcomes were assessed at baseline and at 6, 12, 26, and 52 weeks of follow-up. Data were analyzed with use of mixed models.

RESULTS

Reduced imaging was noninferior compared with routine care in terms of OMAS scores (difference [β], -0.9; 95% confidence interval [CI], -6.2 to 4.4). AAOS scores, HRQoL, pain, health perception, and self-perceived recovery did not differ between groups. Patients in the reduced-imaging group received a median of 4 radiographs, whereas those in the routine-care group received a median of 5 radiographs (p < 0.05). The rates of complications were similar (27.1% [32 of 118] in the reduced-imaging group, compared with 22.7% [29 of 128] in the routine-care group, p = 0.42). The types of complications were also similar.

CONCLUSIONS

Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up. The number of follow-up radiographs can be reduced by implementing this protocol.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Foot and ankle service adaptation in response to COVID-19 and beyond

The disruption to healthcare provision as a result of the COVID-19 pandemic has compelled us to streamline healthcare delivery. This has given us an opportunity to implement healthcare technology, reform inter-disciplinary collaboration and ultimately enhance patient care. We discuss some of the advances made by the foot and ankle department at our hospital. These innovations have broad applicability and will hopefully ignite discussion amoung a number of healthcare teams about improving the future care of their patients.

Primary outcome measures used in interventional trials for ankle fractures: a systematic review

Background

Ankle fractures cause considerable pain, loss of function and healthcare resource use. High quality randomised controlled trials are required to evaluate the optimal management protocols for ankle fracture. However, there is debate regarding the most appropriate outcome measure to use when assessing patients with ankle fractures. The aim of this systematic review is to identify and summarise primary outcome measure use in clinical trials of non-pharmacological interventions for adults with an ankle fracture.

Methods

We performed comprehensive searches of the Medline, Embase, CINAHL, AMED and Cochrane CENTRAL databases, as well as ISRCTN and ClinicalTrials.gov online clinical trial registries on 19/06/2019 with no date limits applied. The titles and abstracts were initially screened to identify randomised or quasi-randomised clinical trials of non-pharmacological interventions for ankle fracture in adults. Two authors independently screened the full text of any articles which could potentially be eligible. Descriptive statistics we used to summarise the outcome measures collected in these articles including an assessment of trends over time. Secondary analysis included a descriptive summary of the multi-item patient reported outcome measures used in this study type.

Results

The searches returned a total of 3380 records. Following application of the eligibility criteria, 121 records were eligible for inclusion in this review. The most frequently collected primary outcome measures in this type of publication was the Olerud Molander Ankle Score, followed by radiographic and range of movement assessments. There was a total of 28 different outcome measures collected and five different multi-item, patient reported outcome measures collected as the primary outcome measure. There was a sequential increase in the number of this type of study published per decade since the 1980’s.

Conclusion

This review demonstrates the wide range of measurement methods used to assess outcome in adults with an ankle fracture. Future research should focus on establishing the validity and reliability of the outcome measures used in this patient population. Formulation of a consensus based core outcome set for adults with an ankle fracture would be advantageous for ensuring homogeneity across studies in order to meta-analyse trial results.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2770-2) contains supplementary material, which is available to authorized users.

Reduction of routine radiographs in the follow-up of distal radius and ankle fractures: Barriers and facilitators perceived by orthopaedic trauma surgeons

RATIONALE, AIMS, AND OBJECTIVES

Studies suggest that routine radiographs during follow-up of distal radius and ankle fractures result in increased radiation exposure and health care costs, without influencing treatment strategies. Encouraging clinicians to omit these routine radiographs is challenging, and little is known about barriers and facilitators that influence this omission. Therefore, this study aims to identify barriers and facilitators among orthopaedic trauma surgeons that might prove valuable towards the design of a deimplementation strategy.

METHODS

A mixed-method approach was used. First, interviews were conducted with orthopaedic trauma surgeons and patients (n = 16). Subsequently, a questionnaire was developed. This questionnaire was presented to 228 orthopaedic trauma surgeons in the Netherlands. Regression analyses were performed in order to identify which variables were independently associated to the decision to stop performing routine radiographs 6 and 12 weeks after trauma if proven not effective in a large randomized controlled trial.

RESULTS

In total, 130 (57%) respondents completed the questionnaire. Of these, 71% indicated they would stop ordering routine radiographs if they were proven not effective. Three facilitators were independent predictors for the intention to omit routine radiographs: This will "lead to lower health care costs" (Odds Ratio [OR]: 5.38 and 4.38), the need for "incorporation in the regional protocol" (OR: 3.66 and 2.66), and this will "result in time savings for the patient" (OR: 4.84).

CONCLUSIONS

We identified three facilitators that could provide backing for a deimplementation strategy aimed at a reduction of routine radiographs for patients with distal radius and ankle fractures.