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Eyler Y, Sever M, Turgut A, Ocak NY, Onata A, Gürsoy O. External validation of the "deformity, edema, and pain in pronation" model for predicting wrist fractures. Am J Emerg Med 2024; 78:95-101. [PMID: 38244246 DOI: 10.1016/j.ajem.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 01/09/2024] [Accepted: 01/09/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND The aim of this study is to externally validate the "Deformity, Edema, and Pain in Pronation" model, which determines the necessity for radiography in patients with wrist trauma. METHODS This prospective, cross-sectional study was performed in a tertiary emergency department (ED). All patients admitted to the ED with wrist trauma aged 18 years and older were included in the study. Patients who did not have acute and blunt wrist trauma, those who could not be fully examined due to various reasons, and patients who did not wish to participate were excluded. Each patient was examined by their responsible physician, and imaging tests were requested based on the indications. All radiographic images were evaluated by an orthopedic surgeon who was blinded to the clinical information. This evaluation was accepted as the standard reference for diagnosing fractures. RESULTS 391 patients were included in the study. 170 patients (43.5%) had at least one fracture. The sensitivity and specificity of the model formed in our study in predicting wrist fractures were 98.77% (95% CI: 95.61-99.85) and 27.60% (95% CI 21.82-34.00), respectively. The area under the receiver operating characteristic curve (AUC) on external validation of the model was 0.878 (p < 0.001; 95% CI: 0.844-0.913). With the practice of this rule, there would be a 16% decrease in X-ray imaging request, while only 0.5% patients would have missed inoperable fractures. CONCLUSION The "deformity, edema, and pain in pronation" model is a reliable and practical clinical decision rule for determining the necessity of radiography in wrist trauma.
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Affiliation(s)
- Yesim Eyler
- Department of Emergency, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey.
| | - Mustafa Sever
- Department of Emergency, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ali Turgut
- Department of Orthopedics and Traumatology, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Necmiye Yalcin Ocak
- Department of Emergency, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ahmet Onata
- Emergency Department, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Olcay Gürsoy
- Department of Emergency, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
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Moellhoff N, Throner V, Frank K, Benne A, Coenen M, Giunta RE, Haas-Lützenberger EM. Epidemiology of hand injuries that presented to a tertiary care facility in Germany: a study including 435 patients. Arch Orthop Trauma Surg 2023; 143:1715-1724. [PMID: 36138241 PMCID: PMC9958136 DOI: 10.1007/s00402-022-04617-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/05/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Hand injuries compose up to 30% of all injuries in emergency care. However, there is a lack of epidemiological data reflecting patient or accident-related variables, injury types, injured anatomical structures or trauma localization. OBJECTIVE The objective of this study is (1) to provide epidemiological information on hand injuries and their patterns and (2) to visualise the frequencies of affected areas of the hand in relation to the most common trauma mechanisms using color-coded heatmaps. METHODS This prospective single-center observational trial conducted at a surgical emergency department in Germany collected data of hand trauma patients using a standardized documentation form. Demographic data, trauma-related data, diagnostic and therapeutic measures were analyzed. Color-coded heatmaps were generated marking anatomic danger zones. RESULTS 435 patients with a mean age of 39.5 were included. Most patients admitted on their own initiative (79%). Leisure and sport injuries were most frequent (75%). Digiti II-V were injured most commonly (43%), followed by metacarpals (19%) and the thumb (14%). Blunt trauma and cuts accounted for most injuries (74%). Hand-graphics depicted color-coded frequencies of the affected areas of the palmar and dorsal aspect of the hand for the most common types of injury, as well as the most frequent circumstances of accident. Elective surgery was recommended in 25% of cases, and hand surgical follow-up was proposed in over 50% of cases. CONCLUSIONS The dorsal aspect of the hand including the 5th metacarpal, the radial wrist and thenar region, as well as the fingertips of Digiti II/III represent anatomic danger zones to injury of the hand. Due to the large variety of potentially injured structures, diagnosis and treatment is not trivial. Specific training is required for all surgical specialties in emergency care, to increase quality of diagnostic work-up and management of hand injuries.
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Affiliation(s)
- Nicholas Moellhoff
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
| | - Veronika Throner
- grid.5252.00000 0004 1936 973XDepartment of Medical Information Processing, Biometry, and Epidemiology (IBE), Chair for Public Health and Health Services Research, Research Unit for Biopsychosocial Health, LMU Munich, Munich, Germany ,Pettenkofer School of Public Health, Munich, Germany
| | - Konstantin Frank
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
| | - Ashley Benne
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
| | - Michaela Coenen
- grid.5252.00000 0004 1936 973XDepartment of Medical Information Processing, Biometry, and Epidemiology (IBE), Chair for Public Health and Health Services Research, Research Unit for Biopsychosocial Health, LMU Munich, Munich, Germany ,Pettenkofer School of Public Health, Munich, Germany
| | - Riccardo E. Giunta
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
| | - Elisabeth M. Haas-Lützenberger
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
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A validation study for a clinical decision rule for acute wrist injury. Eur J Trauma Emerg Surg 2020; 48:4319-4325. [PMID: 32880006 DOI: 10.1007/s00068-020-01474-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Acute wrist injury is a common reason for visiting the emergency department. To date, there are no implemented clinical decision rules to predict a fracture in this group of patients. We previously identified six clinical predictors in adult patients with acute wrist trauma. The aim of this study was to validate these predictors as a decision rule in a validation cohort. METHODS This prospective cohort study was conducted in the emergency department at five hospitals in the Netherlands and included adults with acute wrist injury. All collaborating physicians performed a standardized physical examination and data were collected in a case report form. The main outcome was defined as the radiographic presence of a wrist fracture. Six clinical variables that were significantly associated with a fracture (ρ < 0.01) were included in a model to develop the clinical decision rule. RESULTS A total of 493 fractures in 724 patients were identified by radiographic assessment. Almost all of the clinical variables were associated with the presence of a fracture. Our decision rule had a sensitivity of 0.97 (95% CI 0.96-0.99) with a specificity of 0.26 (95% CI 0.20-0.32) in this validation cohort. Application of the decision rule resulted in a reduction in radiographic assessment rate of 10% at the cost of missing 2% of the fractures. CONCLUSION The decision rule showed a high sensitivity and low specificity, possible due to the high pre-test probability of a wrist fracture in the cohort. Our study needs further validation in other populations.
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Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T. Review article: Best practice management of closed hand and wrist injuries in the emergency department (part 5 of the musculoskeletal injuries rapid review series). Emerg Med Australas 2018; 30:610-640. [DOI: 10.1111/1742-6723.12969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/16/2018] [Accepted: 02/15/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Kirsten Strudwick
- Emergency Department; Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service; Brisbane Queensland Australia
- Physiotherapy Department; Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service; Brisbane Queensland Australia
- School of Health and Rehabilitation Sciences; The University of Queensland; Brisbane Queensland Australia
| | - Megan McPhee
- Physiotherapy Department; Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service; Brisbane Queensland Australia
| | - Anthony Bell
- Emergency and Trauma Centre; Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service; Brisbane Queensland Australia
- Faculty of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - Melinda Martin-Khan
- Centre for Health Services Research; Faculty of Medicine, The University of Queensland; Brisbane Queensland Australia
| | - Trevor Russell
- School of Health and Rehabilitation Sciences; The University of Queensland; Brisbane Queensland Australia
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Karaca Y, Turkmen S, Cansu A, Baki ME, Eroglu O, Tatli O, Gunaydin M, Beyhun E, Gunduz A, Eryiğit U, Baydın A, Güzel M, Özşahin F, Bilir Ö, Şahin A, Taşın V, Kalay A, Gül O, Turedi S. A study to develop clinical decision rules for the use of radiography in wrist trauma: Karadeniz wrist rules. Am J Emerg Med 2016; 34:2074-2078. [PMID: 27450389 DOI: 10.1016/j.ajem.2016.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/06/2016] [Accepted: 07/09/2016] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION The aim of this study was to evaluate patients presenting to the emergency department (ED) with wrist trauma using physical examination findings and functional tests and to identify findings with high sensitivity and specificity among the parameters assessed in patients with fracture in the wrist. The ultimate objective was thus to establish a reliable and widely usable clinical decision rule for determining the necessity of radiography in wrist trauma. METHODS This prospective, multicenter study was performed in 8 hospitals. The relation between radiologically determined fracture and clinical findings consisting of physical examination findings and functional tests was assessed in terms of whether or not these were markers of radiography requirement, with the aim of identifying predictive values for fracture. RESULTS A total of 603 eligible trauma patients presented to the participating EDs during the study period. Fracture was identified in 24.5% of patients (n = 148). The 4-way combination with the highest sensitivity was identified as axial compression and the positive distal radioulnar drawer test, and pain with radial deviation and dorsal flexion. Sensitivity at distal ulna palpation was added as a fifth parameter, and sensitivity and negative predictive value thus increased to 100%. CONCLUSION With their 100% sensitivity and 100% negative predictive values, the Karadeniz wrist rules may represent a clinical decision rule that can be used in practice in EDs. If all 5 findings are negative, there is no indication for wrist radiography.
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Affiliation(s)
- Yunus Karaca
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Suha Turkmen
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey.
| | - Aysegul Cansu
- Karadeniz Technical University, Faculty of Medicine, Department of Radiology, Trabzon, Turkey
| | - Mehmet Emre Baki
- Karadeniz Technical University, Faculty of Medicine, Department of Orthopaedic Surgery, Trabzon, Turkey
| | - Oguz Eroglu
- Kırıkkale University, Faculty of Medicine, Department of Emergency Medicine, Kırıkkale, Turkey
| | - Ozgur Tatli
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Mucahit Gunaydin
- Giresun University, Faculty of Medicine, Department of Emergency Medicine, Giresun, Turkey
| | - Ercument Beyhun
- Karadeniz Technical University, Faculty of Medicine, Department of Public Health, Trabzon, Turkey
| | - Abdulkadir Gunduz
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Umut Eryiğit
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Ahmet Baydın
- Ondokuz Mayıs University, Faculty of Medicine, Department of Emergency Medicine, Samsun, Turkey
| | - Murat Güzel
- Samsun Training and Research Hospital, Department of Emergency Medicine, Samsun, Turkey
| | - Faruk Özşahin
- Giresun State Hospital, Department of Emergency Medicine, Giresun, Turkey
| | - Özlem Bilir
- Recep Tayyip Erdoğan University, Faculty of Medicine, Department of Emergency Medicine, Rize, Turkey
| | - Aynur Şahin
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Veyis Taşın
- Gümüshane State Hospital, Department of Emergency Medicine, Gümüshane, Turkey
| | - Aslan Kalay
- Trabzon Fatih State Hospital, Department of Emergency Medicine, Trabzon, Turkey
| | - Orkun Gül
- Karadeniz Technical University, Faculty of Medicine, Department of Orthopaedic Surgery, Trabzon, Turkey
| | - Suleyman Turedi
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
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