Stiell I G, McDowell I, Nair R C, Aeta H, Greenberg G, McKnight R D, Ahuja J
Department of Family Medicine, University of Ottawa, Ont.
CMAJ. 1992 Dec 1;147(11):1671-8.
To examine the efficiency of the current use of radiography in patients with acute ankle injury. To study the judgements and attitudes of experienced clinicians in their use of ankle radiography and to thereby assess the potential for improved efficiency.
Two-stage study: retrospective chart review and prospective survey.
Emergency departments of two adult teaching hospitals and one community hospital.
The records of 1831 adults presenting with acute blunt trauma to the ankle over 5 months were examined; another 732 patients were seen by 21 full-time emergency staff physicians over a subsequent 6-month period.
Of the 1831 patients with an ankle injury in stage 1, 94.9% had had at least one radiographic series; the yield for clinically important fractures was 12.8%. In stage 2, experienced physicians predicted the probability of fracture to be 0% or 10% in 57.8% of cases. The kappa (kappa) level for interobserver agreement in 98 patients seen independently by two physicians was 0.55 (95% confidence interval [CI] 0.39 to 0.72). The area under the receiver operating characteristic curve for physicians' predicted probability was 0.88 (95% CI 0.84 to 0.92), reflecting good discrimination between fracture and nonfracture cases. Likelihood ratios for predicted probabilities ranged from 0.08 for the 0% level to 151 for the 100% level. The physicians indicated that they would feel comfortable or very comfortable in not ordering radiography in 45.9% of cases (kappa level 0.52; 95% CI 0.34 to 0.70).
Emergency physicians order radiography for most patients with ankle injury even though they can accurately discriminate between fracture and nonfracture cases and clearly expect most of the radiographs to give normal results. These findings suggest great potential for a more efficient use of radiography in patients with ankle injury, possibly through the use of guidelines.
研究当前急性踝关节损伤患者使用X线摄影的效率。探讨经验丰富的临床医生在使用踝关节X线摄影时的判断和态度，从而评估提高效率的潜力。
两阶段研究：回顾性病历审查和前瞻性调查。
两家成人教学医院和一家社区医院的急诊科。
检查了1831例在5个月内因急性钝性踝关节创伤就诊的成年人的病历；在随后的6个月内，21名全职急诊内科医生诊治了另外732例患者。
在第一阶段的1831例踝关节损伤患者中，94.9%至少进行了一次X线摄影系列检查；临床重要骨折的检出率为12.8%。在第二阶段，经验丰富的医生在57.8%的病例中预测骨折概率为0%或10%。两位医生独立检查的98例患者中，观察者间一致性的kappa水平为0.55（95%置信区间[CI]0.39至0.72）。医生预测概率的受试者操作特征曲线下面积为0.88（95%CI0.84至0.92），反映出骨折与非骨折病例之间有良好的区分度。预测概率的似然比范围从0%水平的0.08到100%水平的151。医生表示，在45.9%的病例中不进行X线摄影他们会感到舒适或非常舒适（kappa水平0.52；95%CI0.34至0.70）。
尽管急诊医生能够准确区分骨折与非骨折病例，并且清楚地预期大多数X线摄影结果正常，但他们仍为大多数踝关节损伤患者开具X线摄影检查。这些发现表明，通过使用指南等方式，在踝关节损伤患者中更有效地使用X线摄影具有很大潜力。
