即时超声（PoCUS）在急诊科诊断肩关节脱位和复位的准确性：一项诊断性随机对照试验（RCT）。

Diagnostic accuracy of point-of-care ultrasound (PoCUS) for shoulder dislocations and reductions in the emergency department: a diagnostic randomised control trial (RCT).

机构信息

Emergency Department, Mater Dei Hospital, Msida, Malta

Emergency Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK.

出版信息

Emerg Med J. 2022 Sep;39(9):655-661. doi: 10.1136/emermed-2020-210947. Epub 2021 Sep 20.

DOI:10.1136/emermed-2020-210947

PMID:34544780

Abstract

BACKGROUND

Following blunt trauma, diagnosis of shoulder dislocation based on physical examination alone is difficult due to possible concurrent proximal humeral fractures. X-rays are therefore used to confirm diagnosis. Results from recent observational studies comparing diagnostic accuracy of point-of-care ultrasound (PoCUS) with X-rays for shoulder dislocation have been encouraging. The aim of this study was to determine whether PoCUS improves diagnostic accuracy when used with physical examination for the diagnosis of shoulder dislocation, proximal humeral fracture and ascertaining successful reduction in the ED.

METHODS

A prospective, single-centre, open, parallel randomised control study over a 6-month period was used to answer the research question and test the null hypothesis. Consecutive eligible adult patients attending the ED of Mater Dei Hospital in Malta were randomised to either the control (C) (physical examination only) or experimental group (E) (physical examination and a two-point PoCUS scan). The study objectives were to measure diagnostic accuracy for both examinations for detecting shoulder dislocation, any associated proximal humeral fractures and confirming reduction. X-rays were used as reference standard for both groups.

RESULTS

1206 patients were enrolled in this study (C n=600, E n=606). 290 dislocations (C n=132 and E n=158), 332 proximal humeral fractures (C n=154 and E n=178) and 278 reductions (C n=130 and E n=148) were analysed. A statistically significant difference (p<0.001) was found between the two groups for diagnostic accuracy in shoulder dislocation (C=65%, likelihood ratio (LR)+=2.03 and LR-=0.35 and E=100%, LR+=∞ and LR-=0), proximal humeral fractures (C=45.7%, LR+=1.23 and LR-=0.52 and E=98.3%, LR+=103.9 and LR-=0.03) and reduction (C=68.7%, E=100%). The null hypothesis for this study was thus rejected.

CONCLUSIONS

The addition of PoCUS to a physical examination significantly improves diagnostic accuracy for dislocations, proximal humeral fractures and reduction confirmation.

TRIAL REGISTRATION NUMBER

International Standard Randomised Controlled Trials Number Registry (ISRCTN17048126).

摘要

背景

由于可能同时存在肱骨近端骨折，单纯通过体格检查诊断肩部脱位比较困难。因此，需要使用 X 射线来确认诊断。最近的一些观察性研究比较了超声（PoCUS）和 X 射线在诊断肩部脱位方面的诊断准确性，结果令人鼓舞。本研究旨在确定在急诊科（ED）中，在体格检查的基础上使用 PoCUS 是否可以提高对肩部脱位、肱骨近端骨折的诊断准确性，并确定复位是否成功。

方法

这是一项前瞻性、单中心、开放性、平行随机对照研究，研究期间为 6 个月，旨在回答研究问题并检验零假设。马耳他 Mater Dei 医院的 ED 连续收治符合条件的成年患者，将其随机分配到对照组（C，仅进行体格检查）或实验组（E，进行体格检查和两点 PoCUS 扫描）。研究目的是测量两种检查方法对检测肩部脱位、任何相关的肱骨近端骨折和确认复位的诊断准确性。两组均使用 X 射线作为参考标准。

结果

这项研究共纳入 1206 名患者（C 组 600 名，E 组 606 名）。分析了 290 例脱位（C 组 132 例，E 组 158 例）、332 例肱骨近端骨折（C 组 154 例，E 组 178 例）和 278 例复位（C 组 130 例，E 组 148 例）。两组在肩部脱位（C 组为 65%，优势比（LR）+ = 2.03，LR-= 0.35，E 组为 100%，LR+ = ∞，LR-= 0）、肱骨近端骨折（C 组为 45.7%，LR+ = 1.23，LR-= 0.52，E 组为 98.3%，LR+ = 103.9，LR-= 0.03）和复位（C 组为 68.7%，E 组为 100%）方面的诊断准确性存在统计学显著差异（p<0.001）。因此，该研究的零假设被拒绝。