Ultrasound of the Median Nerve in the Surgical Treatment of Severe Carpal Tunnel Syndrome.

BACKGROUND: High-resolution ultrasound (HRU) has demonstrated utility in the diagnosis and treatment of carpal tunnel syndrome (CTS) by measuring the cross-sectional area (CSA) of the median nerve. We investigated whether HRU could be helpful in evaluating outcomes of carpal tunnel release in patients with severe CTS. METHODS: Patients greater than 18 years of age with severe CTS on electrodiagnostic (EDX) studies and scheduled to have carpal tunnel release were enrolled. At baseline visit within 6 weeks preoperatively, HRU was used to measure median nerve CSA at the carpal tunnel inlet and forearm, and the wrist/forearm ratio (WFR) was calculated. Patients also completed the Boston Carpal Tunnel Questionnaire (BCTQ). Ultrasound and BCTQ were repeated at 6 weeks and 6 months postoperatively. RESULTS: Twelve patients completed the study (average age, 69 years; range, 52-80 years). The WFR improved significantly at 6 weeks and reached normal levels at 6 months. The CSA at the wrist also improved at 6 months, although this did not reach statistical significance (P = .059). Boston Carpal Tunnel Questionnaire symptoms and function scores improved significantly at 6 weeks and 6 months. CONCLUSIONS: High-resolution ultrasound provides an objective assessment of surgical outcomes in cases of severe CTS, demonstrating normalization of WFR in our series of successful cases. Future study of poor outcomes may help determine whether improvement in WFR and CSA can provide reassurance and support for observation rather than reoperation. Ultrasound also provides anatomical evaluation and may be helpful in cases with medicolegal or psychosocial issues while potentially being less costly and better tolerated than EDX or magnetic resonance imaging.

High-Resolution Ultrasound in the Diagnosis and Surgical Management of Ulnar Neuropathy at the Elbow.

High-resolution ultrasound (HRU) has recently demonstrated the potential to facilitate diagnosis and treatment of upper extremity compression neuropathy. The authors hypothesized that HRU can improve preoperative evaluation of ulnar neuropathy at the elbow (UNE) and that changes in ulnar nerve cross-sectional area (CSA) after cubital tunnel release may correlate with outcomes. Nineteen adult patients diagnosed with UNE who were scheduled for surgical decompression by a single hand surgeon were enrolled. Electrodiagnostic (EDX) testing, HRU of the ulnar nerve, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and McGowan grade were obtained pre- and postoperatively. Fourteen patients completed the study. Statistically significant improvements were found in CSA measurements and QuickDASH scores. High-resolution ultra-sound was found to confirm UNE in all 7 patients with positive results on EDX, and additionally detected UNE in 3 of 6 patients with negative results on EDX and in 1 patient with equivocal (nonlocalized) EDX testing. All 4 of these additional HRU-detected cases improved clinically and by CSA measurements after surgery. In this series, HRU was superior to EDX testing in the diagnosis of UNE and demonstrated objective improvement in ulnar nerve CSA after successful cubital tunnel release. This modality, which is better tolerated, less costly, and less time-consuming than EDX testing or magnetic resonance imaging, should therefore be considered in the diagnosis and surgical management of UNE, particularly in cases with negative or equivocal results on EDX testing, or when outcomes are suboptimal. [Orthopedics. 2021;44(5):285-288.].

Cost-Effectiveness of Open Versus Endoscopic Carpal Tunnel Release.

BACKGROUND: Carpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR. METHODS: We developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs). RESULTS: ECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations. CONCLUSIONS: From a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Suture Suspension Arthroplasty for the Treatment of Thumb Carpometacarpal Arthritis.

PURPOSE: Most studies have demonstrated little difference in the outcome of the various techniques proposed for the surgical treatment of thumb carpometacarpal (CMC) arthritis. However, the difficulty and time required to perform each technique vary widely. In addition, the introduction of recent implants has increased the cost of the overall procedure. We hypothesize that using a simple, yet stable, suture suspension technique without tendon interposition or ligament reconstruction yields similar results to conventional approaches with less operative time. METHODS: Three hundred twenty consecutive patients underwent thumb CMC arthroplasty by trapezial excision and metacarpal suspension using #2 high-strength orthopedic suture locked weave alone passed from the distal most abductor pollicis longus and flexor carpi radialis insertions without K-wire fixation or tendon transfer. Average duration of preoperative symptoms was 17.8 months. Patient radiographs were graded for arthritis severity and a visual analog scale (VAS) pain score (scale 0-10) obtained. Postoperative clinical and radiological follow-up averaged 5.4 years (minimum, 24 months). RESULTS: The average age at surgery was 57.3 years and there were 221 women (243 procedures) and 65 men (77 procedures). Average total operative time was 23.4 minutes. The dominant hand was involved in 52% of patients. All had prior treatment including orthoses and nonsteroidal anti-inflammatory drugs with 312 having had at least 1 steroid injection. Five patients had stage 1, 134 had stage 2, 164 had stage 3, and 17 had stage 4 disease on radiographs. Average trapezial space height on final follow-up radiographs was 0.8 cm. Two patients had complete trapezial space collapse and required a revision procedure. The average VAS score was 0.6 with pain eliminated in 269 thumbs, minimal in 49, and unchanged/worse in 2. All patients that were employed at the time of surgery returned to work at an average of 2.3 months (range, 3-16 weeks). CONCLUSIONS: Suture suspension thumb CMC arthroplasty provides comparable clinical results and several advantages over many current techniques that are described in the literature. The advantages include shortened operative time, inherent stability of the thumb metacarpal height, and no necessity for K-wire fixation, tendon transfers, or implants. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pediatric Supracondylar Humerus Fractures: Does After-Hours Treatment Influence Outcomes?

OBJECTIVE: To compare the outcomes of pediatric supracondylar humerus fractures treated during daytime hours to those treated after-hours. DESIGN: Retrospective. SETTING: Academic Level I trauma center. PATIENTS/PARTICIPANTS: Two hundred ninety-eight pediatric patients treated with surgical reduction and fixation of closed supracondylar fractures were included. INTERVENTION: Seventy-seven patients underwent surgery during daytime hours (06:00-15:59 on weekdays). One hundred eighty-six patients underwent surgery after-hours (16:00-05:59 on weekdays and any surgery on weekends or holidays). MAIN OUTCOME MEASURES: Surgeon subspecialty, operative duration, and radiographic and clinical outcomes, including range of motion and carrying angle, were extracted from the patient medical records. RESULTS: There were no patient-related demographic differences between the daytime hours and after-hours groups. Daytime surgery was more likely to be performed by a pediatric orthopaedic surgeon than after-hours surgery. Fractures treated after-hours had more severe injury patterns. After-hours surgery was not independently associated with rate of open reduction, operative times, complications, achievement of functional range of motion, or radiographic alignment. A late-night surgery subgroup analysis demonstrated an increased rate of malunion in patients undergoing surgery between the hours of 23:00 and 05:59. CONCLUSIONS: There is no difference in the operative duration or outcomes after surgical treatment of pediatric supracondylar humerus fractures performed after-hours when compared with daytime surgery. However, late-night surgery performed between 23:00 and 05:59 may be associated with a higher rate of malunion. Surgeons can use these data to make better-informed decisions about the timing of surgery in this patient population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical techniques for the treatment of carpal ligament injury in the athlete.

Treatment of intercarpal ligament injuries in the athlete requires special attention due to several practical and biomechanical considerations. Optimally, the athlete will maintain as much function and range of motion as possible with return to high-impact and load-bearing activity in a timely fashion. Several cutting-edge techniques have arisen in treatment. This article discusses injury patterns in the athlete with scapholunate injury, lunotriquetral injury, scaphotrapezial-trapezoidal injury, and extrinsic ligamentous injury, and the various approaches to addressing these injuries, with a review of the classic as well as newer, innovative techniques.

Quality of internet health information on thumb carpometacarpal joint arthritis.

INTRODUCTION: The Internet has become a heavily used source of health information. No data currently exists on the quality and characteristics of Internet information regarding carpometacarpal (CMC) arthritis. METHODS: The search terms "cmc arthritis," "basal joint arthritis," and "thumb arthritis" were searched using Google and Bing. Search results were evaluated independently by four reviewers. Classification and content specific review was performed utilizing a weighted 100-point information quality scale. RESULTS: Of the 60 websites reviewed, 27 were unique pages with 6 categorized as academic and 21 as non- academic. Average score on content specific review of academic websites was 56.8 and for non-academic was 42.7 (p=0.054). Average Flesch-Kincaid Grade Level for academic websites was 12.4, and for non-academic was 9.9 (p=0.015). CONCLUSION: Internet health information regarding thumb CMC arthritis is primarily non-academic in nature, of generally poor quality, and at a reading level far above the U.S. average reading level of 6th grade. Higher-quality websites with more complete content and appropriate readability are needed. CLINICAL RELEVANCE: The quality of Internet health information regarding thumb CMC arthritis is suboptimal.

A computer assessment of the effect of hindfoot alignment on mechanical axis deviation.

Lower limb malalignment is a common cause of disability that increases risk of osteoarthritis (OA). Treatment of OA may require an osteotomy or arthroplasty, which mandate accurate evaluation of mechanical loading on the limbs to achieve optimal alignment and minimal implant wear. Surgical planning uses a conventional method of mechanical axis deviation (MADC) measured from the center of the femoral head to the center of the ankle. This method fails to account for hindfoot deformity distal to the ankle. We used a computer model to compare MADC with the ground mechanical axis deviation (MADG), drawn from the center of the hip to the ground reaction point. Average anatomic measurements were analyzed with a range of knee and hindfoot angle variation in single leg stance, double leg stance, toe off and heel strike. MADG was consistently higher than MADC, suggesting a more complete estimate of weight-bearing axis that considers hindfoot deformity.

Extensive subcutaneous emphysema resembling necrotizing fasciitis.

Necrotizing fasciitis is an aggressive, invasive soft tissue infection. Because it can rapidly progress to patient instability, prompt diagnosis followed by urgent debridement is critical to decreasing mortality. Despite the importance of early diagnosis, necrotizing fasciitis remains a clinical diagnosis, with little evidence in the literature regarding the effectiveness of diagnostic tools or criteria. Common clinical findings are nonspecific, including pain, blistering, crepitus, and swelling with or without fever and a known infection source.This article describes a patient who was transferred to the authors' institution from another hospital, where she had been taken following seizure activity and was treated with antibiotics for suspected cellulitis at the intravenous catheter placement site on her left dorsal hand. On admission to the current authors' institution, she presented with pain and swelling in the setting of significant left upper-extremity emphysema. She had undergone a left shoulder arthroscopy 4 weeks previously. Vital signs were within normal limits, and a preoperative chest radiograph was read as normal. The patient underwent an emergent fasciotomy, irrigation and debridement of the left upper extremity, and intravenous antibiotics for suspected necrotizing fasciitis. Intraoperative findings indicative of infection were absent, and a left apical pneumothorax was later found on postoperative chest imaging.In a stable patient with a normal chest radiograph on presentation who demonstrates upper-extremity crepitus suspicious for necrotizing fasciitis, a chest computed tomography scan may be indicated to rule out an intrathoracic source.

Preemptive craniectomy with craniotomy: what role in the management of severe traumatic brain injury?

BACKGROUND: Patients with severe traumatic brain injury (TBI) require aggressive management to prevent secondary brain injury. "Preemptive" craniectomy (CE)--craniectomy performed as a primary procedure in conjunction with craniotomy--has been used as prophylaxis for secondary injury, but the indications and outcomes of craniectomy used for this purpose are not well defined. METHODS: To evaluate the role of CE in the management of TBI, we retrospectively reviewed 62 consecutive patients who underwent CE in a 78-month period at our level I trauma center. A cohort of patients who underwent craniotomy only (CO) during this period was compared with the CE group for TBI patterns, indications for operation, and outcomes. Multivariable logistic regression and matched propensity score analysis were used to test the association between CE and survival. The rate of CE was determined by individual neurosurgeons. RESULTS: Of 197 patients with brain injuries who underwent craniotomy, 62 (31.5%) had CE and 135 (68.5%) had CO. Mean age for CE versus CO was 41 years versus 51 years (p < 0.01). Mean admission Glasgow Coma Score was lower in CE versus CO (7.6 vs. 11.8, p < 0.001); Injury Severity Score was higher (30.2 vs. 26.3, p < 0.01). The indication for operation for CE compared with CO was subdural hematoma in 41 (66.1%) versus 87 (64.4%, p = 0.82), epidural hematoma in 2 (3.2%) versus 26 (19.3%, p < 0.01), and cerebral contusion or hematoma in 15 (24.2%) versus 8 (5.9%, p < 0.001). Postoperative intracranial pressure was monitored in 48 (77.4%) CE and 44 (32.6%) CO patients (p < 0.001). Intracranial pressure <20 was maintained in 26 (54.2%) after CE and in 31 (70.5%) after CO (p = 0.12). In the CE group, 26 (42%) died compared with 31 (26%, p < 0.01) in the CO group. When adjusted for severity of injury, however, there was no significant difference in mortality between the two groups (p = 0.134). The CE rate obtained by a neurosurgeon varied from 8.6% to 75.0% (p < 0.001). CONCLUSION: CE was used in patients with more severe injuries, and particularly in those with more severe head injuries. When adjusted for injury severity, CE was not associated with worsened survival, and therefore may reasonably be included in the armamentarium of neurotrauma care. Use of CE by our neurosurgeons, however, varied significantly. These findings underscore the need for practice guidelines based on randomized trials to fully evaluate the role of CE in the management of TBI.

Small catheter tube thoracostomy: effective in managing chest trauma in stable patients.

BACKGROUND: Image-guided small catheter tube thoracostomy (SCTT) is not currently used as a first-line procedure in the management of patients with chest trauma. We adopted a practice recommendation to use SCTT as a less invasive alternative in the treatment of chest injuries. We reviewed our trauma registry to evaluate our change in practice and the effectiveness of SCTT. METHODS: Retrospective review of all tube thoracostomies (TT) performed in patients with chest injury at a level I trauma center from September 2002 through March 2006. Data collected included age, sex, indications and timing for TT, use of antibiotics, length of stay, complications, and outcomes. Large catheter tube thoracostomy (LCTT) not performed in the operating room or trauma room and all SCTT were deemed nonemergent. RESULTS: There were 565 TT performed in 359 patients. Emergent TT was performed in 252 (70%) and nonemergent TT in 157 (44%) patients, of which 63 (40%) received LCTT and 107 (68%) received SCTT. Although SCTT was performed later after injury than nonemergent LCTT (5.5 days vs. 2.3 days, p < 0.001), average duration of SCTT was shorter (5.5 days vs. 7 days, p < 0.05). Rates of hemothoraces were similarly low for SCTT versus nonemergent LCTT (6.1% vs. 4.2%, p = NS) and rates of residual/recurrent pneumothoraces were not significantly different (8% vs. 14%, p = NS). The rate of occurrence of fibrothorax, however, was significantly lower for SCTT compared with nonemergent LCTT (0% vs. 4.2%, p < 0.05). In patients receiving a single nonemergent TT, SCTT was performed in 55 (61%) and LCTT in 35 (39%). A comparison of these groups revealed that SCTT was performed in older patients (p < 0.05), and was associated with a lower Injury Severity Score (p < 0.05) and shorter length of stay (p = 0.05). SCTT was increasingly used in younger and more seriously injured patients as our experience grew. CONCLUSION: SCTT is effective in managing chest trauma. It is comparable with LCTT in stable trauma patients. This study supports adopting image-guided small catheter techniques in the management of chest trauma in stable patients.

Early intubation in the management of trauma patients: indications and outcomes in 1,000 consecutive patients.

BACKGROUND: The Eastern Association for the Surgery of Trauma Practice Management Guidelines identify indications (EI) for early intubation. However, EI have not been clinically validated. Many intubations are performed for other discretionary indications (DI). We evaluated early intubation to assess the incidence and outcomes of those performed for both EI and DI. METHODS: One thousand consecutive intubations performed in the first 2 hours after arrival at our Level I trauma center were reviewed. Indications, outcomes, and trauma surgeon (TS) intubation rates were evaluated. RESULTS: During a 56-month period, 1,000 (9.9%) of 10,137 trauma patients were intubated within 2 hours of arrival. DI were present in 444 (44.4%) and EI in 556 (55.6%). DI were combativeness or altered mental status in 375 (84.5%), airway or respiratory problems in 21 (4.7%), and preoperative management in 48 (10.8%). Injury Severity Score was 14.6 in DI patients and 22.7 in EI patients (p < 0.001). Predicted versus observed survival was 96.6% versus 95.9% in DI patients and 75.2% versus 75.0% in EI patients (p < 0.001). Head Abbreviated Injury Scale score of >or=3 occurred in 32.7% with DI and 52.0% with EI (p < 0.001). Seven (0.7%) surgical airways were performed; two for DI (0.2%). Eleven (1.1%) patients aspirated during intubation and five (0.5%) suffered oral trauma. There were no other significant complications of intubation for either DI or EI and complication rates were similar in the two groups. Delayed intubation (early intubation after leaving the trauma bay) was required in 67 (6.7%) patients and 59 (88.1%) were for combativeness, neurologic deterioration, or respiratory distress or airway problems. Intubation rates varied among TS from 7.6% to 15.3% (p < 0.001) and rates for DI ranged from 3.3% to 7.4% (p < 0.001). There was a statistically insignificant trend among TS with higher intubation rates to perform fewer delayed intubations. CONCLUSIONS: Early intubation for EI as well as DI was safe and effective. One third of the DI patients had significant head injury. Surgical airways were rarely needed and delayed intubations were uncommon. The intubation rates for EI and DI varied significantly among TSs. The Eastern Association for the Surgery of Trauma Guidelines may not identify all patients who would benefit from early intubation after injury.

The need for immediate computed tomography scan after emergency craniotomy for head injury.

BACKGROUND: Patients who undergo emergency craniotomy for head injury require vigilant postoperative (postop) care to obtain the best possible outcome. Although repeat head computed tomography (CT) scans are a key component of the management of these patients, there is no consensus on the optimal timing of the initial postop CT. METHODS: We conducted a retrospective registry-based review of the care of 199 consecutive trauma patients who underwent craniotomy for head injury at a Level I trauma center to evaluate the role of postop CT in their management. RESULTS: One hundred and ninety-nine patients underwent 218 craniotomies for head injury during the 78-month study period. Mean age was 48 years and 73.9% were men. Overall survival was 71.4%. The primary indication for operation included subdural hematoma (SDH) in 136 (62.4%), epidural hematoma (EDH) in 32 (14.7%), intraparenchymal hemorrhage or contusion in 21 (9.6%), depressed skull fracture in 17 (7.8%), and other indications in 12 (5.5%). Postop CTs were obtained after 197 (90.4%) of the operations at a mean of 19.2 hours and revealed a variety of unexpected findings with clinical implications. The only variable statistically associated with unexpected findings was SDH as an indication for operation (p < 0.01). Fourteen (7.0%) patients required a second craniotomy in the 2 days after their initial operation. In six (3.0%) patients, postop CTs were obtained between 4.2 hours and 21.1 hours after initial craniotomy and an earlier postop CT would most likely have prevented a significant delay in operation. Findings in these six patients included recurrent SDH or EDH in two, new SDH or EDH in two, and intraparenchymal hemorrhage in two. Neither neurologic examination nor postop intracranial pressure monitoring reliably predicted the presence of new or recurrent hemorrhage or other significant findings. CONCLUSION: Early, if not immediate, postop CT after emergency craniotomy for head trauma appears to be warranted. We found a significant incidence of unexpected findings on postop CT and encountered avoidable delays in treatment of new or recurrent findings.

The scourge of methamphetamine: impact on a level I trauma center.

BACKGROUND: Methamphetamine (METH) use is associated with high-risk behavior and serious injury. The aim of this study was to assess the impact of METH use in trauma patients on a Level I trauma center to guide prevention efforts. METHODS: A retrospective registry-based review of 4,932 consecutive trauma patients who underwent toxicology screening at our center during a 3-year period (2003-2005). This sample represented 76% of all trauma patients seen during this interval. RESULTS: From the first half of 2003 to the second half of 2005, overall use of METH increased 70% (p < 0.001), surpassing marijuana as the most common illicit drug used by the trauma population. Other illicit drug use did not significantly change during this interval. METH-positive patients were more likely to have a violent mechanism of injury (47.3% vs. 26.3%, p < 0.001), with 33% more assaults (p < 0.01), 96% more gunshot wounds (p < 0.001), and 158% more stab wounds (p < 0.001). They were more likely to have attempted suicide (4.8% vs. 2.6%, p < 0.01), to have had an altercation with law enforcement (1.8% vs. 0.3%, p < 0.001), or been the victim of domestic violence (4.4% vs. 2.1%, p < 0.001). METH users had a higher mean Injury Severity Score (11.2 vs. 10.0, p < 0.01), were 62% more likely to receive mechanical ventilation (p < 0.001), and 53% more likely to undergo an operation (p < 0.001). They were more prone to leave against medical advice (4.9% vs. 2.1%, p < 0.001) and 113% more likely to die from their injuries (6.4% vs. 3.0%, p < 0.001). The average cost of care per METH user was 9% higher than that for nonusers, and METH users were more likely to be unfunded than nonusers (47.6% vs. 23.1%, p < 0.001). The annual uncompensated cost of care of METH users increased 70% during the study period to $1,477,108 in 2005. CONCLUSION: METH use in trauma patients increased significantly and was associated with adverse outcomes and a significant financial burden on our trauma center. Evidence-based prevention efforts must be a priority for trauma centers to help stop the scourge of METH.

What is the role of chest X-ray in the initial assessment of stable trauma patients?

BACKGROUND: The Advanced Trauma Life Support course advocates the liberal use of chest X-ray (CXR) during the initial evaluation of trauma patients. We reviewed CXR performed in the trauma resuscitation room (TR) to determine its usefulness. METHODS: A retrospective, registry-based review was conducted and included 1,000 consecutive trauma patients who underwent CXR in the TR at a Level I trauma center during a 7-month period. RESULTS: Patients receiving CXR comprised 91.5% of all patients evaluated in the TR during the study period. CXR followed by chest computed tomography (CCT) was performed in 820 (82.0%) patients. Subsequent CCT identified missed findings in 235 (35.6%) of the 660 patients with an initial negative CXR who went on to receive CCT. CXR alone was performed in 127 (26.1%) of the 487 patients who were stable, not intubated, and had a normal chest physical examination (CPE). Seven patients (5.5%) in this group had potentially significant findings but none required intervention beyond physiotherapy or antibiotics. Three hundred and sixty (73.9%) of the 487 patients who were hemodynamically stable with a normal CPE underwent both CXR and CCT. Fifty-four patients (15%) in this group had findings of significance, and two (0.6%) required intervention. One patient received bilateral chest tubes for large pre-existing pleural effusions found on CXR and CCT; another patient undergoing general anesthesia required a chest tube for a pneumothorax found only on CCT. CONCLUSION: In stable trauma patients with a normal CPE, CXR appears to be unnecessary in their initial evaluation. CXR should be relegated to a role similar to cervical spine and pelvis radiographs in the initial evaluation of hemodynamically stable trauma patients with a normal physical examination, and should be limited to use only for clear clinical indications.