La radiografía selectiva en la dislocación anterior de hombro: Validación futura de una regla de decisión clínica.
Gregory W. Hendey, M. Kristin Chally and V. Brooks Stewart
UCSF Fresno Medical Education Program: Fresno, CA
OBJECTIVES: To determine whether the use of a clinical decision rule leads to a decrease in pre- and post-reduction radiographs in ED patients with anterior shoulder dislocation, and to assess the safety by determining the frequency of missed fractures or dislocations.
METHODS:Prospective study of adults presenting to the ED with suspected anterior shoulder dislocation. Physicians ordered pre and post-reduction radiographs according to an algorithm based on: 1) whether the dislocation was recurrent, 2) the mechanism of injury, and 3) the physician’s clinical certainty of joint position. Follow-up consisted of phone calls at one and 30 days, orthopedic appointments, and chart review. Actual x-ray utilization was compared to the standard of pre- and post-reduction films in all cases.
RESULTS: Of 76 enrolled patients, 80% were male; mean age was 35 (range 18-72). There were 72 anterior dislocations (4 with greater tuberosity fractures), two AC separations, one clavicle fracture, and one with capsulitis. Of patients with a dislocation, 43 (60%) were recurrent dislocators, with 26 (60%) of those via atraumatic mechanism. 22 (29%) had both pre- and post-reduction films, 28 (37%) had only pre-reduction films, 7 (9%) had only post-reduction films, and 19 (25%) had no radiographs performed. Overall, 79 shoulder radiographs were performed in 76 patients, representing a 47% decrease in film utilization compared to the standard approach. The median ED times were: patients with both pre- and post-reduction films308 mins; pre-reduction only261 mins; post-reduction only237 mins; no radiographs175 mins. On follow-up, there were no clinically significant fractures or persistent dislocations missed, and 75 (99%) of 76 patients were satisfied with their care.
CONCLUSIONS: Using a clinical decision rule for selective radiography, the number of x-rays and ED time were reduced. No fractures or dislocations were missed, and patient satisfaction was high.
Academic Emergency Medicine Volume 11, Number 5 575, © 2004