Risk factors for the presence of important fractures in ED patients with shoulder dislocation: a retrospective cohort study

Sousa, Salomé Delattre; Houzé-Cerfon, Charles Henri; Gourrierec, Thibault Le; Charpentier, Sandrine; Dubucs, Xavier; Balen, Frédéric

doi:10.1136/emermed-2021-211772

Cited by 3 publications

(13 citation statements)

References 14 publications

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“…There were 4688 unique items retrieved from the search process that included eight eligible3–5 17–19 studies reporting data on 2087 individual shoulder dislocations and 343 concomitant fractures (figure 1). There was no evidence of publication bias.…”

Section: Resultsmentioning

confidence: 99%

“…The included studies are described in table 1. There were five retrospective3–5 17 20 and three prospective studies18 19 21 from EDs in Australia,20 Canada,4 18 19 France,17 Iran21 and Turkey 3 5. Three were published by a single research team4 18 19 but over non-overlapping time periods.…”

Section: Resultsmentioning

confidence: 99%

“…Three were published by a single research team4 18 19 but over non-overlapping time periods. Most studies included all adults aged >184 5 17–19 21 or ≥163, but one study limited its population to patients aged <40 years 20…”

Section: Resultsmentioning

confidence: 99%

“…Table 2 shows the risk of bias assessment for each study using the QUADAS-2 tool. Six studies were at low risk of bias in the patient selection category because they reported data from consecutive patients 4 5 17–19 21. However, two studies were at high risk of patient selection bias 3 20.…”

Section: Resultsmentioning

confidence: 99%

“…These issues also gave rise to the only applicability concerns across all of the QUADAS-2 domains. Six studies were at unclear risk of bias in the index test category because they were retrospective studies and did not explicitly state that the assessor recording clinical features was blinded to the results of the radiograph 4 5 17 18 20 21. Similarly, three studies were at unclear risk of bias in the reference standard category because they did not explicitly confirm that the assessor was blinded to the clinical features 4 20 21.…”

Section: Resultsmentioning

confidence: 99%

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Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies

et al. 2022

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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.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies

et al. 2022

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Performance of the Fresno-Quebec Rule in identifying patients with concomitant fractures not requiring a radiograph before shoulder dislocation reduction: a multicenter retrospective cohort study

Benhamed

Bonnet

Miossec

et al. 2023

European Journal of Emergency Medicine

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Background and importance Although shoulder dislocation diagnosis is often solely based on clinical examination, physicians may order a radiograph to rule out a concomitant shoulder fracture before performing reduction. The Fresno-Québec decision rule aims to identify patients requiring a radiograph before reduction to avoid unnecessary systematic imaging. However, this novel approach needs further validation. Objective To evaluate the performance of the Fresno-Québec rule in identifying patients who do not require a prereduction radiograph and assess the variables associated with a clinically significant fracture. Design, settings, and participants A multicenter, retrospective cohort study from 2015 to 2021. Data were extracted from three ED university-affiliated tertiary-care centers. Patients aged ≥18 years with a final diagnosis of anterior glenohumeral dislocation were included. Outcomes measure and analysis Accuracy metrics [sensitivity (Se), specificity (Sp), positive (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR)] of the Fresno-Québec rule were measured. Multivariable logistic regression model was used to identify variables associated with the presence of a concomitant clinically significant fracture. Main results A total of 2129 patients were included, among whom 9.7% had a concomitant fracture. The performance metrics of the Fresno-Québec rule were as follows: Se 0.96 95% confidence interval (0.92–0.98), Sp 0.36 (0.34–0.38), PPV 0.14 (0.12–0.16), NPV 0.99 (0.98–0.99), PLR 1.49 (1.42–1.55) and NLR 0.12 (0.06–0.23). A total of 678 radiographs could have been avoided, corresponding to a reduction of 35.2%. Age ≥40 years, first dislocation episode [odds ratio (OR) = 3.18 (1.95–5.38); P < 0.001], the following mechanisms: road collision [OR = 6.26 (2.65–16.1)], low-level fall [OR = 3.49 (1.66–8.28)], high-level fall [OR = 3.95 (1.62–10.4)], and seizure/electric shock [OR = 10.6 (4.09–29.2)] were associated with the presence of a concomitant fracture. Conclusion In this study, the Fresno-Québec rule has excellent Se in identifying concomitant clinically significant fractures in patients with an anterior glenohumeral dislocation. The use of this clinical decision rule may be associated with a reduction of approximately a third of unnecessary prereduction radiographs.

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Lesiones deportivas de la cintura escapular y el hombro

2023

AMF

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Puntos clave En las tendinopatías del manguito rotador, el dolor, la debilidad y el menor arco de movimiento que persisten después de un programa terapéutico conservador denotan la necesidad de valoración de un tratamiento quirúrgico. La capsulitis adhesiva presenta un patrón articular (limitación de movimientos activos y pasivos) y las maniobras contra resistencia pueden no ser dolorosas. El tratamiento del primer episodio de luxación glenohumeral consiste en la inmovilización con cabestrillo en rotación interna y aducción durante 3-4 semanas. En luxaciones recidivantes se inmovilizará el mínimo tiempo posible hasta la resolución del dolor. En el ámbito extrahospitalario, cuando no se disponga de acceso rápido a radiografías, se puede intentar la reducción cerrada sin radiografía previa en luxaciones glenohumerales recidivantes, menores de 40 años y producidas por traumatismo, baja energía. Ante lesiones traumáticas, se debe descartar siempre mediante exploración posibles lesiones neurovasculares coexistentes. Las lesiones de tipo I y II de la articulación acromioclavicular pueden tratarse de manera conservadora mientras que el resto requiere derivación a traumatología para valorar tratamiento quirúrgico.

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Risk factors for the presence of important fractures in ED patients with shoulder dislocation: a retrospective cohort study

Cited by 3 publications

References 14 publications

Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies

Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies

Performance of the Fresno-Quebec Rule in identifying patients with concomitant fractures not requiring a radiograph before shoulder dislocation reduction: a multicenter retrospective cohort study

Lesiones deportivas de la cintura escapular y el hombro

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