Refinement of the Quebec decision rule for radiography in shoulder dislocation

Abstract

Objective:We prospectively derived a clinical decision rule to guide pre-and postreduction radiography for emergency department (ED) patients with anterior glenohumeral dislocation. Methods: This prospective cohort derivation study took place at 4 university-affiliated EDs over a 3-year period and enrolled consenting patients with anterior glenohumeral dislocation who were 18 years of age or older. We compared patients with a clinically important fracture-dislocation with those who had an uncomplicated dislocation to provide the clinical decision rule components using recursive partitioning. The final rule involved age, mechanism, prior dislocation and humeral ecchymosis. Results: A total of 222 patients were included in the study. Forty (18.0%) had clinically important fracture-dislocation. A clinical decision rule using 4 factors reached a sensitivity of 100% (95% confidence interval [CI] 89.4%-100%), a specificity of 34.2% (95% CI 27.7%-41.2%), a negative predictive value of 99.2% (95% CI 92.8%-99.9%) and a negative likelihood ratio of 0.04 (95% CI 0.002-0.27). Patients younger than 40 years are at high risk for clinically important fracturedislocation only if the mechanism of injury involves substantial force (i.e., a fall greater than their own height, a sport injury, an assault or a motor vehicle collision). Patients 40 years of age or older are at high risk only in the presence of humeral ecchymosis or after their first dislocation. Projected use of the rule would reduce the absolute number of prereduction radiographs by 27.9% and of postreduction by 81.9%. Conclusion: The Quebec shoulder dislocation rule for patients with acute anterior glenohumeral dislocation holds promise to reduce unnecessary imaging, pending validation. RÉSUMÉObjectif : Notre étude visait à établir de façon prospective une règle de décision clinique afin de guider le recours aux radiographies précédant et suivant la réduction chez les patients se présen-tant à l'urgence avec une luxation glénohumérale antérieure. Méthode : Cette étude de dérivation sur une cohorte prospective s'est déroulée sur une période de 3 ans, dans 4 services d'urgence d'hôpitaux universitaires. Nous avons inscrit des patients consentants de 18 ans ou plus qui présentaient une luxation glénohumérale antérieure. Nous avons comparé les patients ayant une luxation ou une fracture cliniquement importante avec ceux qui avaient une luxation sans complication en vue d'établir les critères d'une règle de décision clinique ORIGINAL RESEARCH • RECHERCHE ORIGINALE EM ADVANCES

Failed validation of the Quebec shoulder dislocation rule for young adult patients in an Australian emergency department

“…This is in stark contrast to the 100% sensitivity and 99.2% negative predictive value reported in the derivation study. 7 Unfortunately, the clinical decision rule failed to predict seven clinically significant fractures. When only greater tuberosity fractures were considered, diagnostic performance remained poor.…”

“…In addition, the É mond and colleagues study does not appear to include any patients who had suffered a seizure, although this was not a stated exclusion criterion. 7 Other differences between the samples may include ethnicity, weight, or diet, which have been reported to be factors contributing to fracture. 8 Our findings are a serious threat to the wider adoption of the Quebec shoulder dislocation rule.…”

“…The Quebec shoulder dislocation rule is a clinical decision rule derived by Canadian researchers to allow selective use of radiography in shoulder dislocations. 7 This rule suggests that prereduction radiography is required in young adult patients (aged less than 40 years) if the injury has resulted from a motor vehicle collision, an assault or fight, or a fall from greater than the patient's standing height or if it is a sports injury. A separate rule was derived for older patients.…”

“…To maintain consistency, we used the same definitions as the study that derived the clinical decision rule. 7 The authors defined a clinically significant fracture as a shoulder fracture associated with a shoulder dislocation in which ''special care'' was needed during reduction or in which surgical fixation by orthopedics was needed. This excluded Hill-Sachs lesions but included Bankart lesions, fractures of the humeral head and neck, and greater or lesser tuberosity.…”

CAEP 2014 Academic symposium: “How to make research succeed in your department: How to fund your research program”

“…[1][2][3][4] Most importantly, research can lead to high-quality care and improved outcomes for patients, and to improved efficacy and cost savings for health organizations. [5][6][7][8][9][10][11][12][13] Research funding has a critical impact on the ability of researchers to complete projects, the training and retention of young investigators, and improving emergency health care delivery in Canada.…”