BackgroundPrereduction radiographs are conventionally used to exclude fracture before attempts to reduce a dislocated shoulder in the ED. However, this step increases cost, exposes patients to ionising radiation and may delay closed reduction. Some studies have suggested that prereduction imaging may be omitted for a subgroup of patients with shoulder dislocations.ObjectivesTo determine whether clinical predictors can identify patients who may safely undergo closed reduction of a dislocated shoulder without prereduction radiographs.MethodsA systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. The search was updated to 23 June 2022 and language limits were not applied. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data were pooled and meta-analysed by fitting univariate random effects and multilevel mixed effects logistic regression models.ResultsEight studies reported data on 2087 shoulder dislocations and 343 concomitant fractures. The most important potential sources of bias were unclear blinding of those undertaking the clinical (6/8 studies) and radiographic (3/8 studies) assessment. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (positive likelihood ratio (LR+) 1.8, 95% CI 1.5 to 2.1; negative likelihood ratio (LR−) 0.4, 95% CI 0.2 to 0.6), female sex (LR+ 2.0, 95% CI 1.6 to 2.4; LR− 0.7, 95% CI 0.6 to 0.8), first-time dislocation (LR+ 1.7, 95% CI 1.4 to 2.0; LR− 0.2, 95% CI 0.1 to 0.5) and presence of humeral ecchymosis (LR+ 3.0–5.7, LR− 0.8–1.1). The most important mechanisms of injury were high-energy mechanism fall (LR+ 2.0–9.8, LR− 0.4–0.8), fall >1 flight of stairs (LR+ 3.8, 95% CI 0.6 to 13.1; LR− 1.0, 95% CI 0.9 to 1.0) and motor vehicle collision (LR+ 2.3, 95% CI 0.5 to 4.0; LR− 0.9, 95% CI 0.9 to 1.0). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6% to 99.2%) and a specificity of 33.3% (95% CI 23.1% to 45.3%), but the Fresno-Quebec rule identified all clinically important fractures across two studies: sensitivity of 100% (95% CI 89% to 100%) in the derivation dataset and 100% (95% CI 90% to 100%) in the validation study. The specificity of the Fresno-Quebec rule ranged from 34% (95% CI 28% to 41%) in the derivation dataset to 24% (95% CI 16% to 33%) in the validation study.ConclusionClinical prediction rules may have a role in supporting shared decision making after shoulder dislocation, particularly in the prehospital and remote environments when delay to imaging is anticipated.

Aims, Objectives and BackgroundScaphoid fractures require early identification to avoid complications such as painful non-union, avascular necrosis, and chronic wrist pain. Unfortunately, plain radiographs are insufficiently sensitive and so patients may require immobilisation and further imaging (e.g. MRI) despite normal initial radiographs.The aim of this systematic review was to determine which clinical features best predict the presence of an occult scaphoid fracture that warrants immobilisation and further imaging.Method and DesignA systematic review of diagnostic test accuracy studies was undertaken. All study designs were included if they evaluated predictors of scaphoid fracture amongst patients with normal initial scaphoid radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Depending on the number of studies, data were presented as individual data points, ranges, or meta-analysed by fitting either univariate random effects or multi-level mixed effects logistic regression models.Results and ConclusionEight studies reported data on 1,685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 7.3%. The most accurate predictors of occult scaphoid fracture were pain with supination against resistance (sensitivity 100%, specificity 97.9%, LR 45.0 [95% CI 6.5–312.5], supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR 3.7 [95% CI 2.2–6.1]), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR 2.3 [95% CI 1.8–3.0]), and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR 2.0 [95% CI 1.2–3.2]). The absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture „(sensitivity 92.1, specificity 48.4, LR- 0.2 [95% CI 0.4–0.7]).In conclusion, no single feature can satisfactorily exclude occult scaphoid fracture. However, a number of clinical findings significantly affect the pre-test likelihood of fracture. Future work should determine whether combinations of clinical findings can be used to guide which patients require immobilisation and further imaging despite normal initial radiographs.

BackgroundPlain radiographs cannot identify all scaphoid fractures; thus ED patients with a clinical suspicion of scaphoid injury often undergo immobilisation despite normal imaging. This study determined (1) the prevalence of scaphoid fracture among patients with a clinical suspicion of scaphoid injury with normal radiographs and (2) whether clinical features can identify patients that do not require immobilisation and further imaging.MethodsThis systematic review of diagnostic test accuracy studies included all study designs that evaluated predictors of scaphoid fracture among patients with normal initial radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analyses included all studies.ResultsEight studies reported data on 1685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 9.0%. Most studies were at overall low risk of bias but two were at unclear risk; all eight were at low risk for applicability concerns. The most accurate clinical predictors of occult scaphoid fracture were pain when the examiner moved the wrist from a pronated to a supinated position against resistance (sensitivity 100%, specificity 97.9%, LR+ 45.0, 95% CI 6.5 to 312.5), supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR+ 3.7, 95% CI 2.2 to 6.1), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR+ 2.3, 95% CI 1.8 to 3.0) and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR+ 2.0, 95% CI 1.2 to 3.2). Absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1%, specificity 48.4%, LR- 0.2, 95% CI 0.0 to 0.7).ConclusionNo single feature satisfactorily excludes an occult scaphoid fracture. Further work should explore whether a combination of clinical features, possibly in conjunction with injury characteristics (such as mechanism) and a normal initial radiograph might exclude fracture. Pain on supination against resistance would benefit from external validation.Trial registration numberCRD42021290224.

Aims, Objectives and BackgroundPre-reduction radiographs are conventionally used to exclude important fracture before attempts to reduce a dislocated shoulder in the Emergency Department. However, this step increases cost, exposes patients to ionising radiation, and might delay closed reduction. Some studies have suggested that pre-reduction imaging may be omitted for a sub-group of patients with shoulder dislocations.The objective was to determine whether clinical predictors can identify patients that might safely undergo closed reduction of a dislocated shoulder without pre-reduction radiographs.Method and DesignA systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Data were pooled and meta-analysed by fitting univariate random effects and multi-level mixed effects logistic regression models.Results and ConclusionEight studies reported data on 2,087 shoulder dislocations and 343 concomitant fractures. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (LR+ 1.8 [95% CI 1.5–2.1]; LR- 0.4 [0.2–0.6]), female sex (LR+ 2.0 [1.6–2.4], LR- 0.7 [0.6–0.8]), first time dislocation (LR+ 1.7 [1.4–2.0]; LR-0.2 [0.1–0.5]), and presence of humeral ecchymosis (LR+ 3.0–5.7; LR- 0.8–1.1). The most important mechanisms of injury were: high-energy mechanism fall (LR+ 2.0–9.8), fall >1 flight of stairs (LR+ 3.8 [95% CI 0.6–13.1]; LR- 1.0 [95% CI 0.9–1.0]), and motor vehicle collision (LR+ 2.3 [0.5–4.0]; LR- 0.9 [0.9–1.0]). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6–99.2%) and specificity (33.3%, 23.1–45.3%) but the Fresno-Quebec rule maintained 100% sensitivity across three studies that included 564 shoulder dislocations and 98 fractures.In conclusion, the Fresno-Quebec Rule has undergone both internal and external validation and may now have a role in clinical practice.