Can Clinical Parameters Predict Fractures in Acute Pediatric Wrist Injuries?

Abstract

Abstract. Objective: Fractures around the wrist are common in pediatric patients presenting to the emergency department (ED). This pilot study was aimed at identifying clinical variables that are most likely to be associated with a fracture. Methods: This was a prospective blinded case series of patients 3-18 years of age presenting with an acute (<3 days) wrist injury, without obvious deformity. A team of five investigators blinded to the eventual radiographic findings evaluated patients. Physical examination variables included range of motion (ROM), site of maximal tenderness, and functional deficit. The latter was determined objectively, by recording any difference in grip strength between the injured and noninjured hands. Diagnostic radiographs were obtained for all patients. Univariate analysis using Wilks' log likelihood ratio test was performed to identify clinical variables associated with confirmed wrist fractures. Sample size was determined based on the ability to detect a difference of 15 degrees in the ROM variables, 20% point differences in grip strength, and 30% proportion differences in categorical variables using a power of 0.8 and a two-tailed ␣ of 0.05. Results: The ROMs were not significantly different between the fracture (Fx) and nonfracture (NFx) group. There was significant change in the grip strength between the Fx and NFx groups (t = 3.3, p = 0.0019). Tenderness over the distal radius was also associated with a greater likelihood of a fracture (G 2 = 5.0, p = 0.02). Sensitivity of clinical prediction was found to be 79%, and specificity was 63%. The false-negative rate was 0.21 and the false-positive rate was 0.37, while the positive predictive value was found to be 0.68 and negative predictive value 0.75. Conclusions: Distal radius point tenderness and a 20% or more decrease in grip strength were predictive of fractures.

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

“…All studies excluded patients with neurovascular compromise, distracting injuries, and prior injury or defect to the anatomy of interest. Some studies 27,33 examined both history and physical examination findings, while other studies 25,26,[28][29][30]32 only examined physical examination findings.…”

“…The index test of history or physical examination taking was adequately described and performed to answer the review question in all included studies. Only Cevik et al 27 and Pershad et al 32 occasionally examined inter-rater reliability when feasible. Some studies [26][27][28]32,33 also provided varied types of training in how to obtain history and physical examination data to reduce variability that would occur with multiple examiners performing a test.…”

“…Seventy-six were eliminated based on reference standard, patient type, and study design, leaving seven studies. Two additional studies were identified that fit the inclusion and exclusion criteria after reviewing the references of the prior seven studies, resulting in nine studies (Appelboam et al, 25 Baker and Borland, 26 Cevik et al, 27 Darracq et al, 28 Docherty et al, 29 Hawksworth and Freeland, 30 Lennon et al, 31 Pershad et al, 32 and Webster et al 33 ) that were included in the systematic review of history and physical examination findings that were suggestive of upper extremity fracture.…”

“…The sample size ranged from 48 32 to 1,740 patients. 25 Of the nine included trials, six 25,26,[28][29][30][31] studied elbow injuries, and three 27,32,33 studied wrist injuries.…”

“…The overall quality of the included trials was variable. Some studies used convenience [26][27][28]32,33 sampling and other studies used consecutive 25,[29][30][31] sampling. The inclusion and exclusion criteria were clearly defined by all studies, and no inappropriate exclusions were noted.…”