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Ready-Access CT Imaging for an Orthopaedic Trauma Clinic
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D Cawley , A Hennessy
, P Curtin
, D Bergin
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Departments of
Trauma & Orthopaedics, and
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,
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F Shannon
Radiology, Galway University Hospital, Newcastle Rd, Galway
Abstract
Ready-Access to CT imaging facilities in Orthopaedic Trauma Clinics is not a standard facility. This facility
has been available at the regional trauma unit, in Merlin Park Hospital, Galway for the past four years. We reviewed
the use of this facility over a 2-year period when 100 patients had CT scans as part of their trauma clinic
assessment. The rate of CT scan per clinic was 0.6. The mean waiting time for a CT scan was 30 minutes. 20 (20%) new
fractures were confirmed, 33 (33%) fractures were out-ruled, 25 (25%) fractures demonstrated additional information
and 8 (8%) had additional fractures. 20 (20%) patients were discharged and 12 (12%) patients were admitted as a result
of the CT scan. It adds little time and cost to CT scanning lists.
Introduction
The trauma unit in Galway serves as a regional referral centre for a hinterland population of
approximately 300,000
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people, with an additional 1.2 million tourists visiting each year
. Referrals to the Orthopaedic Trauma Service come
from the Emergency Departments of one regional and two district hospitals and are seen the following day at the trauma
clinic of the consultant on call. The management of these patients can normally be decided on the basis of clinical
evaluation and plain x-rays but occasionally further imaging is necessary. CT scan is the imaging modality of choice
for definitive multi-dimensional imaging of the skeleton. Ready-access to CT scanning from the orthopaedic trauma
clinic typically implies that a CT scan is added to the end of a planned list or scheduled within a few days of the
clinic. It is useful for evaluation of a suspected fracture, to aid preoperative planning for intra-articular
fractures, and occasionally to confirm bony union at follow up. MRI is limited mostly because of its restricted
availability, cost, and length of scan time. Radionuclide bone scanning, while sensitive for bone pathology, has
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similar cost implications, is not specific for acute trauma and displays poor anatomic localisation
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CT scanning has proven to be of benefit in determining3,4the presence or absence of fractures in cases of high clinical
suspicion, particularly carpal fractures
. Nguyen et al have demonstrated the value of CT with a clinical
scaphoid fracture
at an upper limb clinic in making an earlier diagnosis and commencing more timely and appropriate
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treatment
. Three-dimensional CT image reconstruction of intra-articular fractures enhances delineation of complex
joint fractures and occult fractures, showing
the exact number of fractures and their degree of displacement
which
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aids pre-operative planning
. CT is also used to monitor union of fractures
. It has been proposed that the cost and
total radiation dose compared
to special projections of conventional radiographs is equivalent to that of
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multi-detector CT
.
Ready-access to multi-detector CT scanning for fractures or suspected fractures has been available at the
orthopaedic trauma clinic in Merlin Park Hospital, Galway for the past four years. The scanner, 75 metres from the
trauma clinic, is a private/public facility and is made available to patients at this public clinic because the costs
and logistics of referring a patient to the nearest public only access CT scanner are greater. The clinic digital
viewing radiography network (IMPAX RISTM, Agfa-Gaevert, Belgium) also extends to the CT scanner so that images can be
viewed on screen at the trauma clinic. In our study we aimed to determine the benefits of ready-access CT
scanning in terms of time to diagnosis, operative management and facilitating early discharge from the trauma clinic.
The burden placed on the radiology department as a result of providing this service was also quantified.
Methods
We undertook case review of 100 consecutive patients attending the trauma clinic at Merlin Park Hospital over a
two-year period (2008/2009) who had a CT scan requested from the trauma clinic as part of their assessment. We
collected information including the initial radiographic report, the clinical indication for CT and the CT report. We
also looked at the time elapsed between requesting the CT and the scan being performed. We then looked at the further
management of these patients i.e. if operative management was undertaken, conservative management and outpatient
review or discharge from the clinic.
Results
Incidence of CT scans performed was 0.6 per day (SD 0.88), with 100 patients requiring a CT scan over 170 trauma
clinics. These included 51 men and 49 women, with a mean age of 37.4 years. All patients were referred from Accident &
Emergency Units in the region and had already been reviewed by at least two doctors. Some patients were being
monitored for a healing fracture at the trauma clinic. Average waiting time between clinic consultation and CT scan
was 49 minutes. Two patients had to wait until the following morning for their scan. Excluding these, average waiting
time was 30mins (SD 42mins). Total scan time was typically 15 minutes, including procedure explanation, patient
positioning and image processing. The equivalent cost per scan for a private patient is 300, regardless of the area
of interest, costing approximately 44,000 per annum. All scans had reconstructive images done and were reported
within an hour by a radiologist. CT results are summarised in Table 1. Admission/discharge subsequent management
following the CT scan is shown in Table 2.
Ready-Access CT Imaging for an Orthopaedic Trauma Clinic
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20 patients were discharged from the clinic on the basis of their CT findings (Table 2). 12 patients were admitted for
operative management. 10 of these had new findings on their CT that were not identified on x-ray and subsequent
management was based on CT findings. The remaining 2 patients had CT to assist pre-operative planning, with the
decision to operate being made prior to CT.
The Dose Length Product is a measure of total radiation exposure for the whole series of images per body part scan.
Table 3 presents DLP values for averages achieved in 2009 for this scanner. It indicates that the radiation doses
exposed per scan are consistent with low international values.
Discussion
Bone-specific CT scans rarely require the use of intravenous contrast, which allows for faster and less
labour-intensive scanning. The quality of the image is unaffected by the position of the patient or the angulation of
the scan and repeat views are unnecessary. A frequent cause of discordance amongst the radiography and orthopaedic
services is re-x-ray for visualising an acute fracture where the initial radiograph did not adequately demonstrate the
fracture or joint integrity, such as the ankle or shoulder joint. This is frequently compounded by an unwilling
patient with a painful limb. The additional information provided by a CT scan over plain radiography on a patients
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fracture was clearly shown in this study. Both new trauma patients and symptomatic review patients benefitted in each
case-20% of patients had confirmation of a new fracture, 31% had confirmation of no fracture and 41% gained additional
information about their fracture- new or old.
Our results demonstrate a low rate of referral for this service. Less than 1 patient on average per day required a CT
scan. The prompt scan and report availability allowed a patient to be seen afterwards, before the trauma clinic had
finished thus facilitating a prompt decision on the patients fracture management. 20% of patients were discharged
and 12 % were admitted after their CT scan. It is possible that these patients may have been similarly managed
regardless. Discharged patients with the additional benefit of CT posed obvious advantages to clinical burden and
earlier mobilisation out of cast thus allowing an individual back to work. Regarding those admitted for operative
treatment, the benefits of pre-operative multi-detection CT for gaining additional information have been proven. What
remain obscure within the remaining 68%, are patients who did not have surgery because of the CT result, patients who
went on to have earlier alternative investigations or patients whose conservative outpatient management was altered as
a result, through adaptation of their physiotherapy regime, plaster duration or weight-bearing status. This was
particularly relevant for those eight patients who had additional contiguous fractures.
Most CT scans for spinal trauma should be appropriately imaged in the Accident & Emergency department. Despite efforts
to maintain a quality of care that ensures adequate imaging of acute spinal trauma, some patients slip through the net
with sub-standard imaging. It is worth mentioning that the four CT scans of the spine would ideally have been imaged
at initial evaluation in A&E. Typically there is ready access to CT scanning facilities in these circumstances. The
Dose Length Product amounts used with this multidetector scanner compare favourably with other contemporary scanners.
Radiation dosage per scan was lower than typical trauma scans because scans were more focussed after multiple clinical
examinations than those performed in the A&E setting, thus a smaller area needs imaging. It is difficult to equate
benefit in terms of cost for this facility. Calculating the cost of multiple clinical visits, additional radiographs
and longer absence from work accounts for only a part of the economic picture. The benefits to earlier diagnosis or
better fracture management are tangible.
Ready-access CT imaging is the standard of care at the orthopaedic trauma clinic in Merlin Park Hospital, Galway. This
is justified as an on-demand facility for an orthopaedic trauma clinic. Despite the relatively low burden it places on
the scanning department, it facilitates a definitive diagnosis when plain films are insufficient, enabling a decision
on further treatment to be made at a single OPD attendance. The can-do philosophy of the private sector is
beneficial to the public service in this regard, with no resistance to extra work-load. It facilitates early discharge
of patients who might otherwise need to be followed up at subsequent clinics. It is also evidence of an exemplary
public-private relationship within the healthcare spectrum whose benefits affect both parties involved.
Acknowledgements
The Merlin Park Imaging Centre for their co-operation in this study.
Correspondence: F Shannon
Department of Trauma & Orthopaedic Surgery, Merlin Park Hospital, Galway
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Ready-Access CT Imaging for an Orthopaedic Trauma Clinic
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