Kiel Cecilie Mullerup, Mikkelsen Kim Lyngby, Krogsgaard Michael Rindom
Section for Sports Traumatology M51, Bispebjerg-Frederiksberg Hospital (Part of IOC Research Center Copenhagen), University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark.
Danish Patient Compensation Association, Kalvebod Brygge 45, 1560, Copenhagen, NV, Denmark.
BMC Musculoskelet Disord. 2018 Jul 21;19(1):244. doi: 10.1186/s12891-018-2170-z.
Tibial plateau fractures (TPFs) are sometimes overlooked in the emergency room (ER). Using a national register covering 18 years we aimed to find out why and to evaluate if use of a specific radiographic decision rule, Pittsburgh Knee Rules (PKRs), could have reduced the number of overlooked TPFs.
Medical records for 137 patients, prospectively registered during 18 years by the Danish Patient Compensation Association (DPCA) (a national register), were studied. The inclusion criterion was a delayed diagnosis of a fracture in the knee following a trauma. Case records, legal assessments, and evaluations by specialist doctors were reviewed, and the consequences of the delayed diagnosis for outcome and treatment were registered.
Only 58 patients (42%) had been evaluated according to PKRs. In 53 patient cases, the fracture was not diagnosed on radiographs obtained at the first medical contact. However, in 84% of these cases, the fracture was visible or was suspected by retrospective evaluation. 50 out of 79 patients, for whom X-rays were not obtained, were candidates for radiographs according to PKRs, 17 cases lacked information to evaluate by PKRs and 12 cases were not candidates. In 53% of all cases, it was evaluated that the fracture position had worsened at the time of diagnosis. A significant disability compensation was granted in 36% of cases due to the delayed identification of fractures, totaling 841,000 EUR.
The major reasons for overlooking TPFs were 1) difficulty in recognizing the fractures on X-rays and 2) that X-ray decision rules were not employed. Two thirds of the patients, for whom a radiograph had not been prescribed, would have had an X-ray, if the PKRs had been used. Overlooking TPFs significantly increased patient disability in one third of cases. We recommend that healthcare professionals in the ER use X-ray decision rules in addition to clinical examination to avoid overlooking TPFs. When standard radiographs are evaluated as normal in patients that are clinically suspect of a TPF, oblique X-rays, magnetic resonance imaging (MRI) or Computed Tomography (CT)-scan should be considered.
胫骨平台骨折（TPF）在急诊室（ER）有时会被忽视。我们利用一个涵盖18年的国家登记系统，旨在找出原因，并评估使用特定的影像学决策规则——匹兹堡膝关节规则（PKR）是否能减少被忽视的TPF数量。
研究了丹麦患者赔偿协会（DPCA）（一个国家登记系统）在18年期间前瞻性登记的137例患者的病历。纳入标准为创伤后膝关节骨折的延迟诊断。回顾了病例记录、法律评估和专科医生的评估，并记录了延迟诊断对预后和治疗的影响。
只有58例患者（42%）按照PKR进行了评估。在53例患者中，首次就医时拍摄的X线片未诊断出骨折。然而，在这些病例中，84%的骨折通过回顾性评估可见或被怀疑。在79例未进行X线检查的患者中，50例根据PKR符合进行X线检查的条件，17例缺乏用PKR评估的信息，12例不符合条件。在所有病例的53%中，评估认为骨折位置在诊断时恶化。由于骨折的延迟识别，36%的病例获得了高额残疾赔偿，总计841,000欧元。
忽视TPF的主要原因是1）X线片上难以识别骨折，2）未采用X线决策规则。如果使用PKR，三分之二未开具X线检查的患者本应进行X线检查。在三分之一的病例中，忽视TPF显著增加了患者残疾程度。我们建议急诊室的医护人员除临床检查外，使用X线决策规则以避免忽视TPF。当临床上怀疑TPF的患者标准X线片评估正常时，应考虑进行斜位X线、磁共振成像（MRI）或计算机断层扫描（CT）检查。
