Emergency Department, Hull Royal Infirmary, Hull, UK.
Emerg Med J. 2014 May;31(5):380-3. doi: 10.1136/emermed-2012-202169. Epub 2013 Feb 8.
To derive a maximally sensitive decision rule for clinical practice to rule out the need for x-ray examination after elbow injury in adults and children.
Emergency department patients with acute elbow injury were recruited. Practitioners used their usual judgement to assess whether x-ray examination was required. Radiographs were reported on by radiologists blind to clinical assessment. Patients not x-rayed were followed-up at 7 days by telephone interview, and those with ongoing pain were recalled for assessment. Recursive partitioning was used to derive a maximally sensitive decision tool. Inter-rater variability for significant discriminators was subsequently evaluated by a cohort of 20 emergency department clinicians.
492 patients were recruited (May 2006-November 2008): 50.4% were male; 26.8% were children; 444 (90.2%) had an x-ray; 167 (37.6%) showed abnormality. A follow-up telephone interview was conducted with 28; none were recalled. Thirteen could not be contacted, none of whom returned within 3 months. Sixteen patients with fractures were able to fully extend their elbow. The sensitivity of elbow extension alone was 84% (95% CI 77% to 88%), with specificity of 54% (95% CI 53% to 58%). A 100% sensitive (95% CI 97% to 100%) decision rule for adults (n=348) was derived based on (1) inability to fully extend the elbow, (2) tenderness over radial head, olecranon or medial epicondyle, and (3) presence of bruising (specificity 24% (95% CI 19% to 30%)). A similar rule for children could not be derived.
A simple and highly sensitive clinical decision rule for adult elbow fracture was derived in our cohort. A validation study in a second population is now required. At present, we are unable to recommend a rule-out strategy for elbow injuries in children.
制定一种最敏感的决策规则，以排除成人和儿童肘部外伤后行 X 射线检查的必要性。
招募急诊科急性肘部损伤患者。医生根据自己的判断评估是否需要进行 X 射线检查。放射科医生在不知临床评估的情况下报告 X 射线检查结果。未行 X 射线检查的患者通过电话随访在 7 天进行随访，对持续疼痛的患者进行召回评估。递归分割用于推导最敏感的决策工具。随后，由 20 名急诊科临床医生组成的队列评估重要鉴别因素的观察者间变异性。
共纳入 492 例患者（2006 年 5 月至 2008 年 11 月）：男性占 50.4%，儿童占 26.8%，444 例（90.2%）进行了 X 射线检查，167 例（37.6%）显示异常。对 28 例患者进行了电话随访，其中 13 例无法联系，在 3 个月内均无回复。16 例骨折患者能完全伸直肘部。单独使用肘部伸展的敏感性为 84%（95%CI 77%至 88%），特异性为 54%（95%CI 53%至 58%）。根据（1）无法完全伸展肘部，（2）桡骨头、尺骨鹰嘴或内上髁压痛，（3）存在瘀斑，得出成人（n=348）的 100%敏感（95%CI 97%至 100%）决策规则，特异性为 24%（95%CI 19%至 30%）。无法为儿童制定类似的规则。
在我们的队列中得出了一种简单且高度敏感的成人肘部骨折临床决策规则。现在需要在第二个人群中进行验证研究。目前，我们无法推荐肘部外伤患儿的排除策略。
