Matthew Vella
Too many x-rays are being taken of patients with nasal fractures, leading to “a substantial financial burden” on the national health system, doctors writing in the Malta Medical Journal claim.
A study on the financial implications of nasal fractures at St Luke’s Hospital (SLH) found that only 16% of the patients who had x-rays of their nasal injuries taken, needed surgical intervention.
The doctors warned that patients attending the Accident & Emergency Department with nasal injuries “should not routinely have radiological examinations unless requested by a specialist”.
Nasal injuries are the third most common type of fractures, usually due to traffic accidents, falls, and fights, leading to numerous patient visits at the hospital emergency department.
According to the period under study, in 2006 there were 278 x-rays of nasal bones taken at St Luke’s emergency department. This strongly contrasted with the 46 operations conducted on nasal fractures.
The figures show the majority of patients examined for nasal trauma do not require any surgery under general anaesthesia, surgeons Nadia Sciberras and Hermann Borg Xuereb said.
“Abolishing unnecessary investigations would allow better re-allocation of funds… allowing an improvement in the health system with a superior service offered to the patient,” the surgeons said.
The “over-investigation” of nasal fractures was also leading to unnecessary costs for x-rays.
The surgeons said the price for a small x-ray film was €0.98 – a total expenditure for the year of €272.20 – without taking into consideration development and fixing of the film, upkeep of the x-ray machine, and labour costs. At Mater Dei, x-rays are now also digitalised.
But the same process costs €76.93 in the private sector, which would result in a total expenditure of €21,384 every year.
The surgeons say EU guidelines rarely indicate x-rays for nasal fractures. “Nasal x-rays are likely to miss nearly 50% of nasal fractures, while old fractures, vascular markings and suture lines can lead to false-positive results.”
Instead they recommended that nasal injuries should be followed up a week after the injury, and only if a deformity persists should a nasal x-ray be taken.
“Such a management not only protects most patients from unnecessary radiation but it is also very cost-effective since most nasal fractures do not need to be reduced,” the surgeons said.
They also recommended that since a diagnosis of nasal injuries is often needed because such fractures often involve the police and legal proceedings, doctors should consider any nasal fracture as GBH – without having to resort to x-rays unless a specialist requires it.
“Any injury resulting in lacerations that will leave a scar on the nose (and hence the face) or that results in psychological effects lasting more than 30 days should be considered to be an act of grievous bodily harm… a thorough history and examination is all that is needed to diagnose a nasal fracture.”
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