Jie Kim E, van Dam Lisette F, Verhagen Thijs F, Hammacher Eric R
Department of Emergency Medicine, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands.
Department of Emergency Medicine, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands.
Ann Emerg Med. 2014 Jul;64(1):74-8. doi: 10.1016/j.annemergmed.2014.01.022. Epub 2014 Feb 13.
Elbow injury is a common presentation at the emergency department (ED). There are no guidelines indicating which of these patients require radiography, whereas clinical decision rules for other limb injuries are widely accepted and resulted in less radiography and reduced waiting times. We aim to identify clinical signs that can be used to predict the need for radiography in elbow injury.
A prospective observational study at 2 ED locations in the Netherlands was performed. For every eligible patient with acute elbow injury, elbow extension and addition of point tenderness at the olecranon, epicondyles, and radial head were evaluated for predicting the need for radiography (primary endpoint). A subgroup of patients was assessed by a blinded second investigator to analyze interobserver variability (secondary endpoint). All patients received anterior-posterior and lateral elbow radiographs. Fractures were treated according to current guidelines and patients were followed at outpatient clinics.
In total, 587 patients were included. Normal extension was observed in 174 patients (30%). Normal extension predicted absence of a fracture or isolated fat pad with 88% sensitivity and 55% specificity. Five patients with normal extension had a fracture that required surgery. Absence of point tenderness in patients with normal extension was observed in only 24 patients, of whom 3 showed a fracture and 1 required surgery. Addition of point tenderness to the extension test to predict absence of a fracture or isolated fat pad resulted in 98% sensitivity and 11% specificity. Interobserver analysis for extension and palpation of olecranon, epicondyles, and radial head resulted in κ values between 0.6 and 0.7.
In contrast with previous studies, ours shows that in acute elbow injury, the extension test alone or in combination with point tenderness assessment does not safely rule out clinically significant injury. Interobserver variability was substantial. We would not recommend the use of the extension test (+/- point tenderness assessment) as a clinical decision rule to guide radiologic diagnostics in acute elbow trauma.
肘部损伤是急诊科常见的就诊情况。目前尚无指南表明哪些此类患者需要进行X光检查，而其他肢体损伤的临床决策规则已被广泛接受，并减少了X光检查的使用及缩短了等待时间。我们旨在确定可用于预测肘部损伤患者是否需要进行X光检查的临床体征。
在荷兰的2个急诊科开展了一项前瞻性观察研究。对于每例符合条件的急性肘部损伤患者，评估其肘部伸展情况以及尺骨鹰嘴、髁上和桡骨头处有无压痛，以预测是否需要进行X光检查（主要终点）。由一名不知情的第二位研究者对一组患者进行评估，以分析观察者间的变异性（次要终点）。所有患者均接受肘部正侧位X光片检查。骨折按照现行指南进行治疗，患者在门诊接受随访。
共纳入587例患者。174例患者（30%）肘部伸展正常。肘部伸展正常对排除骨折或单纯脂肪垫的敏感性为88%，特异性为55%。5例肘部伸展正常的患者发生了需要手术治疗的骨折。在肘部伸展正常的患者中，仅24例无压痛，其中3例有骨折，1例需要手术。将压痛检查加入伸展试验以预测排除骨折或单纯脂肪垫，敏感性为98%，特异性为11%。对尺骨鹰嘴、髁上和桡骨头的伸展及触诊进行观察者间分析，κ值在0.6至0.7之间。
与既往研究不同，我们的研究表明，在急性肘部损伤中，单独的伸展试验或与压痛评估相结合，均不能安全排除具有临床意义的损伤。观察者间变异性较大。我们不建议将伸展试验（±压痛评估）作为临床决策规则来指导急性肘部创伤的放射学诊断。
