Interventions to reduce imaging in children with upper or lower extremity injuries: a systematic review and meta-analysis

Clinical Snapshot

Key Findings

• P Value: Clinical guidelines: p<0.001; Ankle and wrist decision rule CIs do not cross 1.0, indicating statistical significance

• Effect Size: Ankle decision rules: OR=0.11 (89% reduction in imaging odds); Wrist decision rule: OR=0.06 (94% reduction in imaging odds); Triage nurse implementation: OR=5.44 (444% increase in imaging odds); Clinical guidelines: statistically significant reduction in radiographs per patient

• Primary Outcome: Reduction in radiographic imaging in children with extremity injuries in the ED following implementation of clinical decision rules or guidelines

• Nnt Or Sensitivity: Safety signal: 8 missed injuries with wrist decision rule implementation; 16 missed injuries with triage nurse-led decision rule implementation. NNT/NNH not calculable from abstract data. I²=38% for ankle decision rule subgroup (moderate heterogeneity)

• Confidence Interval: Ankle decision rules: 95% CI 0.07 to 0.16; Wrist decision rule: 95% CI 0.03 to 0.11; Triage nurse implementation: 95% CI 2.96 to 10.02

Clinical Application

Clinical decision rules for ankle injuries appear feasible and effective when implemented by physicians. Wrist decision rules show large imaging reductions but carry a meaningful missed injury rate (8 cases), requiring careful patient selection and robust safety-netting. Triage nurse-led implementation is not supported by current evidence and may paradoxically increase imaging while also missing injuries. Implementation requires staff training, clear eligibility criteria, and systematic follow-up protocols. In Australia, paediatric ED imaging stewardship aligns with the RACGP and Australasian College for Emergency Medicine (ACEM) quality improvement priorities. The Ottawa Ankle Rules are already referenced in Australian emergency medicine practice, and this review supports their continued use in paediatric populations. Radiation protection is governed by ARPANSA guidelines, and reducing unnecessary paediatric X-ray exposure is consistent with Australian radiation safety policy. The PBS does not directly fund ED imaging decisions, but reducing unnecessary imaging has cost implications for Medicare and hospital budgets. Australian paediatric EDs with triage nurse practitioner models should exercise caution given the safety signals identified. The TGA does not regulate clinical decision rules, but ACEM and the Royal Australasian College of Surgeons may consider these findings in guideline updates. Children presenting to emergency departments with ankle or wrist injuries where validated clinical decision rules (analogous to Ottawa Ankle Rules adapted for paediatric populations) are applicable. Results are most directly applicable to physician-led implementation in paediatric or general EDs.

Abstract

BACKGROUND: Radiation exposure, transition delays and costs associated with unnecessary imaging in children have stimulated research into clinical decision rules and other interventions to reduce imaging in the emergency department (ED). The objective of this systematic review is to examine the effectiveness of implementing interventions to reduce imaging in children with upper/lower extremity injuries in the ED. METHODS: Seven databases and the grey literature were searched up to May 2024. Comparative studies assessing interventions to reduce imaging in children with upper/lower extremity injuries implemented in the ED were eligible. Two independent reviewers screened for study eligibility, quality assessment and data extraction, with disagreements settled via third-party adjudication. Changes in imaging are reported as ORs with 95% CIs, using a random effects model. RESULTS: From 9387 citations, eight unique studies enrolling 7793 children were included with the majority using a before-after design. Potential concerns for bias were documented due to a lack of reporting of key quality domains. Decision rules for ankle injuries successfully reduced radiography (OR=0.11; 95% CI 0.07 to 0.16, I2=38%). A decision rule for wrist injuries reduced imaging (OR=0.06; 95% CI 0.03 to 0.11); however, eight injuries were missed. Two studies implementing clinical guidelines reported decreases in radiographs per patient (p<0.001). One trial reported increased imaging in children assessed by triage nurses using an established clinical decision rule (OR=5.44; 95% CI 2.96 to 10.02), with 16 missed injuries identified. CONCLUSIONS: Guidelines incorporating clinical decision rules, particularly decision rules for ankle injuries, can reduce radiography for children with extremity injuries in the ED. Further investigations are warranted to identify other extremity injuries, the components of the intervention and the most efficient clinicians to target. PROSPERO REGISTRATION NUMBER: CRD42016042875.

References

1. 1.Kirkland, S. W., Lesyk, N., Herle, E., Yang, E., Ushko, J., Villa-Roel, C., Campbell, S., Krebs, L. D., Sevcik, W., & Rowe, B. H. (2026). Interventions to reduce imaging in children with upper or lower extremity injuries: a systematic review and meta-analysis. Emergency Medicine Journal. Advance online publication. https://doi.org/10.1136/emermed-2025-215355