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Introduction of the “Straight-Leg-Evaluation-Trauma-Test” as a rapid assessment for long-bone fractures in a trauma bay setting. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
OBJECTIVES Injuries are one of the most common causes of pediatric emergency department (ED) visit. The aim of this study was to investigate the relationship between the intensity of pain at the ED visit of children presenting with an extremity injury and the risk of fracture. METHODS We conducted a retrospective study, considering all patients presenting to the ED of a children's hospital in Italy, with an accidental extremity injury, between May and December 2015. We selected all children aged 8 to 17 years who underwent an x-ray. Children with major, multiple, or nonextremity injuries were excluded. Age, sex, spontaneous and palpation pain, local swelling, time between injury, and medical evaluation were recorded. Sensibility and specificity of spontaneous and palpation pain in detecting a fracture were calculated. RESULTS We reviewed 994 medical records; of these, 344 (34.6%) reported a fracture. Children's median age was 12 years (interquartile range [IQR], 10-14). Median spontaneous pain at the ED visit was not significantly different between children with and without a fracture: 4.0 (1.0-6.0) and 5 (1.0-6.0), respectively (P = 0.129). Children with mild palpation pain and children without an increase of pain of at least 2 points between spontaneous and palpation pain were fractured in 3.2% and 0.97% of cases, respectively. CONCLUSIONS In this series, pain intensity in children with a minor extremity injury was not a good marker of fracture. Nevertheless, children with mild palpation pain or with a mild increase of pain between spontaneous and palpation pain had a low risk of fracture.
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Hepping AM, Barvelink B, Ploegmakers JJW, van der Palen J, Geertzen JHB, Bulstra SK, Harbers JS, Stevens M. Recovery of strength after reduced pediatric fractures of the forearm, wrist or hand; A prospective study. PLoS One 2020; 15:e0230862. [PMID: 32236117 PMCID: PMC7112181 DOI: 10.1371/journal.pone.0230862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 03/10/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction The way strength recovers after reduction of pediatric fractures of the upper extremity has not previously been the specific scope of research. This is remarkable, since strength measurements are often used as an outcome measure in studies on trauma of the upper extremity. The aim of this study was to evaluate how strength recovers after sustainment of fractures of the forearm, wrist or hand treated by closed or open reduction in children and adolescents in the first 6 months after trauma. How much strength is lost at 6 weeks, 3 months and 6 months after trauma, and is this loss significant? Are there differences in the pattern of recovery between children who underwent a different treatment? And finally, which of the following factors are associated with an increase in the ratio between affected grip strength and expected strength: type of fracture, cast immobilization, occurrence of complications, and degree of pain? Design Prospective observational study. Participants Children and adolescents aged 4–18 years with a reduced fracture of the forearm, wrist or hand. Methods Grip strength, key grip and three-jaw chuck grip were measured twice in each hand 6 weeks, 3 months and 6 months after trauma. Details on fracture type and location, treatment received, cast immobilization and complications were obtained. Hand-dominance and pain were verbally confirmed. Results Loss of strength was more prominent and prolonged the more invasive the treatment, hence most extensive in the group receiving open reduction with internal fixation (ORIF), intermediate in the group receiving closed reduction with percutaneous pinning (CRIF), and least extensive in the group undergoing closed reduction without internal fixation (CR). Besides time passed, gender and age were of significant influence on strength, although there was no difference in pattern of recovery over time between children who received a different treatment. In the period of 6 weeks to 3 months after trauma, female gender, type of fracture sustained and occurrence of an unwanted event were associated with an increased ratio between affected and expected grip strength. For the later phase of recovery, between 3 and 6 months, this was only true for the occurrence of an unwanted event.
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Affiliation(s)
- Ann M. Hepping
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Roessingh Center for Rehabilitation, Enschede, The Netherlands
- * E-mail:
| | - Britt Barvelink
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joris J. W. Ploegmakers
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Job van der Palen
- Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, The Netherlands
- Medisch Spectrum Twente, Medical School Twente, Enschede, The Netherlands
| | - Jan H. B. Geertzen
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Sjoerd K. Bulstra
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jorrit S. Harbers
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin Stevens
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Giacalone M, Capua T, Shavit I. Short and long arm cast and pain after discharge in children who underwent reduction of distal forearm fracture in the Emergency Department: A study protocol for a randomized comparative effectiveness study. Contemp Clin Trials Commun 2018; 11:46-49. [PMID: 30003167 PMCID: PMC6040576 DOI: 10.1016/j.conctc.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/25/2018] [Accepted: 06/01/2018] [Indexed: 11/30/2022] Open
Abstract
Distal forearm fracture is the most common fracture in childhood. Patients with this type of injury suffer from meaningful pain after Emergency Department (ED) discharge. Previous studies demonstrated that short arm (below-the-elbow) casts perform as well as long arm (above-the-elbow) casts for maintaining the reduction of distal forearm fractures, with a similar rate of complications. Consequently, short casts are the commonly used method of immobilization after closed reduction of a distal forearm fractures in children older than 4 years. However, short casts carry a potential disadvantage; since they cannot prevent supination in a wrist that is held in pronation, and vice versa, their use might be associated with pain. We initiated this study to examine the effect of the type of casting on post discharge pain. We will conduct an open-label randomized, controlled trial comparing short cast immobilization with long cast immobilization in children who had a reduction of distal forearm fracture in the ED. Our hypothesis is that children with distal forearm fractures who are treated with a long cast, experience less pain during the first 48 h after ED discharge than children who are treated with a short cast.
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Affiliation(s)
- Martina Giacalone
- Department of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Tali Capua
- Emergency Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Itai Shavit
- Emergency Department, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Corresponding author. POB 274, Kibutz Maayan Tzvi, 3080500, Israel.
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Mulders MAM, Walenkamp MMJ, Slaar A, Ouwehand F, Sosef NL, van Velde R, Goslings JC, Schep NWL. Implementation of the Amsterdam Pediatric Wrist Rules. Pediatr Radiol 2018; 48:1612-1620. [PMID: 29992444 PMCID: PMC6153883 DOI: 10.1007/s00247-018-4186-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/04/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The Amsterdam Pediatric Wrist Rules have been developed and validated to reduce wrist radiographs following wrist trauma in pediatric patients. However, the actual impact should be evaluated in an implementation study. OBJECTIVE To evaluate the effect of implementation of the Amsterdam Pediatric Wrist Rules at the emergency department. MATERIALS AND METHODS A before-and-after comparative prospective cohort study was conducted, including all consecutive patients aged 3 to 18 years presenting at the emergency department with acute wrist trauma. The primary outcome was the difference in the number of wrist radiographs before and after implementation. Secondary outcomes were the number of clinically relevant missed fractures of the distal forearm, the difference in length of stay at the emergency department and physician compliance with the Amsterdam Pediatric Wrist Rules. RESULTS A total of 408 patients were included. The absolute reduction in radiographs was 19% compared to before implementation (chi-square test, P<0.001). Non-fracture patients who were discharged without a wrist radiograph had a 26-min shorter stay at the emergency department compared to patients who received a wrist radiograph (68 min vs. 94 min; Mann-Whitney U test, P=0.004). Eight fractures were missed following the recommendation of the Amsterdam Pediatric Wrist Rules. However, only four of them were clinically relevant. CONCLUSION Implementing the Amsterdam Pediatric Wrist Rules resulted in a significant reduction in wrist radiographs and time spent at the emergency department. The Amsterdam Pediatric Wrist Rules were able to correctly identify 98% of all clinically relevant distal forearm fractures.
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Affiliation(s)
- Marjolein A. M. Mulders
- 0000000404654431grid.5650.6Trauma Unit, Department of Surgery, Academic Medical Center, P.O. Box 22660, Meibergdreef, 91105 AZ Amsterdam, The Netherlands
| | - Monique M. J. Walenkamp
- 0000000404654431grid.5650.6Trauma Unit, Department of Surgery, Academic Medical Center, P.O. Box 22660, Meibergdreef, 91105 AZ Amsterdam, The Netherlands
| | - Annelie Slaar
- grid.476832.cDepartment of Radiology, Westfriesgasthuis, P.O. Box 600, 1620 AR Hoorn, The Netherlands
| | - Frank Ouwehand
- 0000000404654431grid.5650.6Emergency Department, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Nico L. Sosef
- 0000 0004 0568 6419grid.416219.9Department of Surgery, Spaarne Gasthuis, P.O. Box 770, 2130 AT Hoofddorp, The Netherlands
| | - Romuald van Velde
- Department of Surgery, Tergooi Hospitals, P.O. Box 10016, 1201 DA Hilversum, The Netherlands
| | - J. Carel Goslings
- grid.440209.bDepartment of Surgery, Onze Lieve Vrouwe Gasthuis, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands
| | - Niels W. L. Schep
- 0000 0004 0460 0556grid.416213.3Department of Trauma and Hand Surgery, Maasstad Hospital, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands
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External validation of clinical decision rules for children with wrist trauma. Pediatr Radiol 2017; 47:590-598. [PMID: 28246898 PMCID: PMC5391386 DOI: 10.1007/s00247-017-3787-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/12/2016] [Accepted: 01/26/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Clinical decision rules help to avoid potentially unnecessary radiographs of the wrist, reduce waiting times and save costs. OBJECTIVE The primary aim of this study was to provide an overview of all existing non-validated clinical decision rules for wrist trauma in children and to externally validate these rules in a different cohort of patients. Secondarily, we aimed to compare the performance of these rules with the validated Amsterdam Pediatric Wrist Rules. MATERIALS AND METHODS We included all studies that proposed a clinical prediction or decision rule in children presenting at the emergency department with acute wrist trauma. We performed external validation within a cohort of 379 children. We also calculated the sensitivity, specificity, negative predictive value and positive predictive value of each decision rule. RESULTS We included three clinical decision rules. The sensitivity and specificity of all clinical decision rules after external validation were between 94% and 99%, and 11% and 26%, respectively. After external validation 7% to 17% less radiographs would be ordered and 1.4% to 5.7% of all fractures would be missed. Compared to the Amsterdam Pediatric Wrist Rules only one of the three other rules had a higher sensitivity; however both the specificity and the reduction in requested radiographs were lower in the other three rules. CONCLUSION The sensitivity of the three non-validated clinical decision rules is high. However the specificity and the reduction in number of requested radiographs are low. In contrast, the validated Amsterdam Pediatric Wrist Rules has an acceptable sensitivity and the greatest reduction in radiographs, at 22%, without missing any clinically relevant fractures.
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Slaar A, Walenkamp MMJ, Bentohami A, Maas M, van Rijn RR, Steyerberg EW, Jager LC, Sosef NL, van Velde R, Ultee JM, Goslings JC, Schep NWL. A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules. Pediatr Radiol 2016; 46:50-60. [PMID: 26298555 PMCID: PMC4706582 DOI: 10.1007/s00247-015-3436-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/26/2015] [Accepted: 07/09/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND In most hospitals, children with acute wrist trauma are routinely referred for radiography. OBJECTIVE To develop and validate a clinical decision rule to decide whether radiography in children with wrist trauma is required. MATERIALS AND METHODS We prospectively developed and validated a clinical decision rule in two study populations. All children who presented in the emergency department of four hospitals with pain following wrist trauma were included and evaluated for 18 clinical variables. The outcome was a wrist fracture diagnosed by plain radiography. RESULTS Included in the study were 787 children. The prediction model consisted of six variables: age, swelling of the distal radius, visible deformation, distal radius tender to palpation, anatomical snuffbox tender to palpation, and painful or abnormal supination. The model showed an area under the receiver operator characteristics curve of 0.79 (95% CI: 0.76-0.83). The sensitivity and specificity were 95.9% and 37.3%, respectively. The use of this model would have resulted in a 22% absolute reduction of radiographic examinations. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7-8.3%) would have been missed using the decision model. CONCLUSION The decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required.
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Affiliation(s)
- Annelie Slaar
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Monique M. J. Walenkamp
- Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Abdelali Bentohami
- Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105, AZ Amsterdam, The Netherlands
| | - Rick R. van Rijn
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105, AZ Amsterdam, The Netherlands
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - L. Cara Jager
- Emergency Department, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Nico L. Sosef
- Department of Surgery, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Romuald van Velde
- Department of Surgery, Tergooi Hospitals, Hilversum, The Netherlands
| | - Jan M. Ultee
- Department of Surgery, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands
| | - J. Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Niels W. L. Schep
- Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands ,Department of Surgery, Maasstadziekenhuis Rotterdam, Rotterdam, The Netherlands
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Golding LP, Yasin Y, Singh J, Gyr BM, Gardner A, Anthony E. Imaging of the elbow in children with wrist fracture: an unnecessary source of radiation and use of resources? Pediatr Radiol 2015; 45:1169-73. [PMID: 25715709 DOI: 10.1007/s00247-015-3304-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/02/2015] [Accepted: 02/04/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Anecdotally accepted practice for evaluation of children with clinically suspected or radiographically proven wrist fracture in many urgent care and primary care settings is concurrent imaging of the forearm and elbow, despite the lack of evidence to support additional images. These additional radiographs may be an unnecessary source of radiation and use of health care resources. OBJECTIVE Our study assesses the necessity of additional radiographs of the forearm and elbow in children with wrist injury. MATERIALS AND METHODS We reviewed electronic medical records of children 17 and younger in whom wrist fracture was diagnosed in the emergency department. We identified the frequency with which additional radiographs of the proximal forearm and distal humerus demonstrated another site of acute injury. RESULTS We identified 214 children with wrist fracture. Of those, 129 received additional radiographs of the elbow. Physical examination findings proximal to the wrist were documented in only 16 (12%) of these 129 children. A second injury proximal to the wrist fracture was present in 4 (3%) of these 129 children, all of whom exhibited physical examination findings at the elbow. No fractures were documented in children with a negative physical examination of the elbow. CONCLUSION Although elbow fractures occasionally complicate distal forearm fractures in children, our findings indicate that a careful physical evaluation of the elbow is sufficient to guide further radiographic investigation. Routine radiographs of both the wrist and elbow in children with distal forearm fracture appear to be unnecessary when an appropriate physical examination is performed.
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Affiliation(s)
- Lauren P Golding
- Department of Radiology, Wake Forest University Baptist Health, Medical Center Boulevard, Winston-Salem, NC, 27157, USA,
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Brants A, IJsseldijk MA. A pilot study to identify clinical predictors for wrist fractures in adult patients with acute wrist injury. Int J Emerg Med 2015; 8:2. [PMID: 25852772 PMCID: PMC4385052 DOI: 10.1186/s12245-015-0050-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 01/22/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To date, no clinical decision rules for acute wrist injuries are available. In the past, clinical decision rules for the knee, ankle and spine injuries have been developed and validated. Implementation of these rules resulted in standardised clinical assessment at the emergency department and a substantial reduction of radiographic diagnostics. The objective of the study was to identify predictors for wrist fractures in patients with acute wrist injury which might potentiate a clinical decision rule in the future. This is a prospective pilot study in adult patients presenting with acute wrist injury at the emergency department of the Canisius-Wilhelmina Hospital in the Netherlands. METHODS Clinical variables were collected in a case report file by emergency physicians. Radiography was ordered according to common practice to confirm or rule out the presence of fractures. Independent associations between the presence of clinical variables and wrist fractures were calculated. Multivariable analysis was performed in order to quantify sensitivity and specificity for fracture prediction. RESULTS A total of 63 wrist fractures were detected in the study population of 95. Age over 55 years, inability to carry weight directly after trauma, support of injured wrist by the contralateral hand for pain relief, presence of swelling and/or hematoma, visible wrist deformity and reduced range of motion were associated with the presence of a wrist fracture. CONCLUSIONS Our study identified clinical predictors for wrist fractures in patients with acute wrist injury. Future studies are needed for justification of evidence-based wrist assessment and identification of a 100% sensitive decision rule for wrist fractures.
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Affiliation(s)
- Anne Brants
- Emergency Department, Canisius-Wilhelmina Ziekenhuis (CWZ), Postbox 9015, 6500 GS Nijmegen, the Netherlands
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Gould SJ, Cardone DA, Munyak J, Underwood PJ, Gould SA. Sideline coverage: when to get radiographs? A review of clinical decision tools. Sports Health 2014; 6:274-8. [PMID: 24790698 PMCID: PMC4000478 DOI: 10.1177/1941738114529701] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
CONTEXT Sidelines coverage presents unique challenges in the evaluation of injured athletes. Health care providers may be confronted with the question of when to obtain radiographs following an injury. Given that most sidelines coverage occurs outside the elite level, radiographs are not readily available at the time of injury, and the decision of when to send a player for radiographs must be made based on physical examination. Clinical tools have been developed to aid in identifying injuries that are likely to result in radiographically important fractures or dislocations. EVIDENCE ACQUISITION A search for the keywords x-ray and decision rule along with the anatomic locations shoulder, elbow, wrist, knee, and ankle was performed using the PubMed database. No limits were set regarding year of publication. We selected meta-analyses, randomized controlled trials, and survey results. Our selection focused on the largest, most well-studied published reports. We also attempted to include studies that reported the application of the rules to the field of sports medicine. STUDY DESIGN Retrospective literature review. LEVEL OF EVIDENCE Level 4. RESULTS The Ottawa Foot and Ankle Rules have been validated and implemented and are appropriate for use in both pediatric and adult populations. The Ottawa Knee Rules have been widely studied, validated, and accepted for evaluation of knee injuries. There are promising studies of decision rules for clinically important fractures of the wrist, but these studies have not been validated. The elbow has been evaluated with good outcomes via the elbow extension test, which has been validated in both single and multicenter studies. Currently, there are no reliable clinical decision tools for traumatic sports injuries to the shoulder to aid in the decision of when to obtain radiographs. CONCLUSION Clinical decision tools have been developed to aid in the diagnosis and management of injuries commonly sustained during sporting events. Tools that have been appropriately validated in populations outside the initial study population can assist sports medicine physicians in the decision of when to get radiographs from the sidelines.
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Affiliation(s)
- Sara J Gould
- Regional Orthopedics, New York, New York ; Department of Emergency Medicine, NYU Langone Medical Center, New York, New York
| | - Dennis A Cardone
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York ; Center for Musculoskeletal Care, NYU Langone Medical Center, New York, New York
| | - John Munyak
- Department of Orthopedics Surgery, Maimonides Medical Center, Maimonides Bone & Joint Center, New York, New York
| | - Philipp J Underwood
- Department of Emergency Medicine, Sports Medicine, North Shore-LIJ Health System, Manhasset, New York
| | - Stephen A Gould
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
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Joshi N, Lira A, Mehta N, Paladino L, Sinert R. Diagnostic accuracy of history, physical examination, and bedside ultrasound for diagnosis of extremity fractures in the emergency department: a systematic review. Acad Emerg Med 2013; 20:1-15. [PMID: 23570473 DOI: 10.1111/acem.12058] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/09/2012] [Accepted: 08/05/2012] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Understanding history, physical examination, and ultrasonography (US) to diagnose extremity fractures compared with radiography has potential benefits of decreasing radiation exposure, costs, and pain and improving emergency department (ED) resource management and triage time. METHODS The authors performed two electronic searches using PubMed and EMBASE databases for studies published between 1965 to 2012 using a strategy based on the inclusion of any patient presenting with extremity injuries suspicious for fracture who had history and physical examination and a separate search for US performed by an emergency physician (EP) with subsequent radiography. The primary outcome was operating characteristics of ED history, physical examination, and US in diagnosing radiologically proven extremity fractures. The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). RESULTS Nine studies met the inclusion criteria for history and physical examination, while eight studies met the inclusion criteria for US. There was significant heterogeneity in the studies that prevented data pooling. Data were organized into subgroups based on anatomic fracture locations, but heterogeneity within the subgroups also prevented data pooling. The prevalence of fracture varied among the studies from 22% to 70%. Upper extremity physical examination tests have positive likelihood ratios (LRs) ranging from 1.2 to infinity and negative LRs ranging from 0 to 0.8. US sensitivities varied between 85% and 100%, specificities varied between 73% and 100%, positive LRs varied between 3.2 and 56.1, and negative LRs varied between 0 and 0.2. CONCLUSIONS Compared with radiography, EP US is an accurate diagnostic test to rule in or rule out extremity fractures. The diagnostic accuracy for history and physical examination are inconclusive. Future research is needed to understand the accuracy of ED US when combined with history and physical examination for upper and lower extremity fractures.
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Affiliation(s)
- Nikita Joshi
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn NY
| | - Alena Lira
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn NY
| | - Ninfa Mehta
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn NY
| | - Lorenzo Paladino
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn NY
| | - Richard Sinert
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn NY
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Splinting versus casting of “torus” fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): A literature review. Int Emerg Nurs 2009; 17:173-8. [DOI: 10.1016/j.ienj.2009.03.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Revised: 03/12/2009] [Accepted: 03/17/2009] [Indexed: 11/19/2022]
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Webster AP, Goodacre S, Walker D, Burke D. How do clinical features help identify paediatric patients with fractures following blunt wrist trauma? Emerg Med J 2006; 23:354-7. [PMID: 16627835 PMCID: PMC2564082 DOI: 10.1136/emj.2005.029249] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Wrist injuries are a common presentation to the emergency department (ED). There are no validated decision rules to help clinicians evaluate paediatric wrist trauma. This study aimed to identify which clinical features are diagnostically useful in deciding the need for a wrist radiograph, and then to develop a clinical decision rule. METHODS This prospective cohort study was carried out in the ED of Sheffield Children's Hospital. Eligible patients were recruited if presenting within 72 hours following blunt wrist trauma. A standardised data collection form was completed for all patients. The outcome measure was the presence or absence of a fracture. Univariate analysis was performed with the chi2 test. Associated variables (p<0.2) were entered into a multivariate model. Classification and regression tree (CART) analysis was used to derive the clinical decision rule. RESULTS In total, 227 patients were recruited and 106 children were diagnosed with fractures (47%). Of 10 clinical features analysed, six were found by univariate analysis to be associated with a fracture. CART analysis identified the presence of radial tenderness, focal swelling, or an abnormal supination/pronation as the best discriminatory features. Cross fold validation of this decision rule had a sensitivity of 99.1% (95% confidence interval 94.8% to 100%) and a specificity of 24.0% (17.2% to 32.3%). The radiography rate would be 87%. CONCLUSIONS Radial tenderness, focal swelling, and abnormal supination/pronation are associated with wrist fractures in children. The clinical decision rule derived from these features had a high sensitivity, but low specificity, and would not substantially alter our current radiography rate. The potential for a clinical decision rule for paediatric wrist trauma appears limited.
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Affiliation(s)
- A P Webster
- Department of Intensive Care Medicine, Sir Charles Gairdner Hospital, Nedlands, Perth, Australia.
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