Brand et al proposed a protocol for performing X-rays on patients with an injured extremity. This was intended to reduce the number of unnecessary radiographic examinations.


Study population: 848 patients with 1235 injuries

Site of Injury


upper or lower extremity

bone deformity


bone instability




point tenderness

upper extremity only

ecchymosis in an upper extremity


severe swelling in an upper extremity

lower extremity only

moderate to severe pain on weight bearing in a hip or thigh


any positive finding in a knee


number of positive criteria =

= SUM(number of findings present)



• high risk = presence of one or more positive criteria

• low risk = no positive criteria present

• An X-ray is recommended if the injury is high risk.

• The protocol could have reduced X-ray usage by 12% for upper extremity studies and 19% for lower extremity studies.

• 1 fracture in 287 was missed, but the treatment given was appropriate and the outcome was satisfactory.


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