Stiell I G, Wells G A, McDowell I, Greenberg G H, McKnight R D, Cwinn A A, Quinn J V, Yeats A
University of Ottawa, Ontario, Canada.
Acad Emerg Med. 1995 Nov;2(11):966-73. doi: 10.1111/j.1553-2712.1995.tb03123.x.
To study: 1) the efficiency of the current use of radiography in acute knee injuries, 2) the judgments and attitudes of experienced clinicians in their use of knee radiography, and 3) the potential for decision rules to improve efficiency.
This two-stage study of adults with acute knee injuries involved: 1) a retrospective review of all 1,967 patients seen over a 12-month period in the EDs of one community and two teaching hospital, and 2) a prospective survey of another 1,040 patients seen by attending emergency physicians. The prospective survey assessed each clinician's estimate of the probability of a knee or patella fracture; 120 patients were independently assessed by two physicians.
Of the 1,967 patients seen in the first stage, 74.1% underwent radiography but only 5.2% were found to have fractures. Of the 1,727 knee and patella radiographic series ordered, 92.4% were negative for fracture. In the second stage, experienced physicians predicted the probability of fracture to be 0 or 0.1 for 75.6% of the patients. The kappa value for this response was 0.51 (95% CI 0.34 to 0.68). The physicians also indicated that they would have been comfortable or very comfortable in not ordering radiography for 55.5% of the patients. The area under the receiver operating characteristics curve for the physicians' prediction of fracture was 0.87 (95% CI 0.82 to 0.91), reflecting good discrimination between fracture and nonfracture cases. Likelihood ratios for the physicians' prediction ranged from 0.09 at the 0 level to 42.9 at the 0.9-1.0 level.
Emergency physicians order radiography for most patients with acute knee injuries, even though they can accurately discriminate between fracture and nonfracture cases and expect most of the radiographs to be normal. These findings suggest great potential for more efficient use of knee radiography, possibly through the use of a clinical decision rule.
研究：1）当前X线摄影在急性膝关节损伤中的应用效率；2）经验丰富的临床医生在使用膝关节X线摄影时的判断和态度；3）决策规则提高效率的潜力。
这项针对急性膝关节损伤成人患者的两阶段研究包括：1）回顾在一个社区和两家教学医院急诊科12个月期间就诊的所有1967例患者；2）对另1040例由急诊主治医师诊治的患者进行前瞻性调查。前瞻性调查评估了每位临床医生对膝关节或髌骨骨折概率的估计；120例患者由两位医生独立评估。
在第一阶段就诊的1967例患者中，74.1%接受了X线摄影，但仅5.2%被发现有骨折。在开出的1727例膝关节和髌骨X线摄影检查中，92.4%的检查结果为骨折阴性。在第二阶段，经验丰富的医生对75.6%的患者预测骨折概率为0或0.1。该反应的kappa值为0.51（95%可信区间0.34至0.68）。医生们还表示，对于55.5%的患者，即使不进行X线摄影他们也会感到舒适或非常舒适。医生预测骨折的受试者工作特征曲线下面积为0.87（95%可信区间0.82至0.91），表明在骨折和非骨折病例之间有良好的区分度。医生预测的似然比范围从0水平的0.09到0.9 - 1.0水平的42.9。
急诊医生为大多数急性膝关节损伤患者开具X线摄影检查，尽管他们能够准确区分骨折和非骨折病例，并且预计大多数X线检查结果正常。这些发现表明，通过使用临床决策规则，更有效地使用膝关节X线摄影具有很大潜力。
