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Refinement of the Quebec decision rule for radiography in shoulder dislocation

Published online by Cambridge University Press:  21 May 2015

Marcel Émond ,
Natalie Le Sage ,
André Lavoie  and
Lynne Moore
Marcel Émond*
Affiliation:
Centre Hospitalier Affilié, Universitaire de Québec, Québec City, Que. Department of Family Medicine, Emergency Medicine Section, Laval University, Québec City, Que.
Natalie Le Sage
Affiliation:
Centre Hospitalier Affilié, Universitaire de Québec, Québec City, Que. Department of Family Medicine, Emergency Medicine Section, Laval University, Québec City, Que.
André Lavoie
Affiliation:
Centre Hospitalier Affilié, Universitaire de Québec, Québec City, Que. Department of Social and Preventative Medicine, Laval Univeristy, Québec City, Que.
Lynne Moore
Affiliation:
Centre Hospitalier Affilié, Universitaire de Québec, Québec City, Que. Department of Social and Preventative Medicine, Laval Univeristy, Québec City, Que.
*
Unité de recherche en traumatologie, urgence et soins intensifs, Centre Hospitalier Affilié, Site Enfant-Jésus, 1401, rue 18eme, Québec City QC G1J 1Z4; [email protected]

Abstract

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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 fracture-dislocation 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.

Keywords

anterior shoulder dislocationemergency medicineclinical decision rulesshoulder fractures
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 11 , Issue 1 , January 2009 , pp. 36 - 43
Copyright
Copyright © Canadian Association of Emergency Physicians 2009

References

1.Kroner, K, Lind, T, Jensen, J.The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg 1989;108:288–90.Google Scholar
2.Nordqvist, A, Petersson, CJ.Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 1995;4:107–12.Google Scholar
3.Mohamud, D.Shoulder, in Rosens’s Emergency Medicine: concepts and clinical practice, Marx, J., editor. St. Louis. (MO): Mosby; 2002. p. 576–606.Google Scholar
4.Cleeman, E, Flatow, EL.Shoulder dislocations in the young patient. Orthop Clin North Am 2000;31:217–29.Google Scholar
5.Stayner, LR, Cummings, J, Andersen, J, et al.Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231–9.CrossRefGoogle Scholar
6.Émond, M, Le Sage, N, Lavoie, A, et al.Clinical factors predicting fractures associated with an anterior shoulder dislocation. Acad Emerg Med 2004;11:853–8.Google Scholar
7.Harvey, RA, Trabulsy, ME, Roe, L.Are postreduction anteroposterior and scapular Y views useful in anterior shoulder dislocations? Am J Emerg Med 1992;10:149–51.Google Scholar
8.Hendey, GW.Necessity of radiographs in the emergency department management of shoulder dislocations. Ann Emerg Med 2000;36:108–13.Google Scholar
9.Hendey, GW, Chally, MK, Stewart, VB.Selective radiography in 100 patients with suspected shoulder dislocation. J Emerg Med 2006;31:23–8.Google Scholar
10.Shuster, M, Abu-Laban, RB, Boyd, J, et al.Prospective evaluation of a guideline for the selective elimination of pre-reduction radi-ographs in clinically obvious anterior shoulder dislocation. CJEM 2002:4:257–62.Google Scholar
11.Shuster, M, Abu-Laban, RB, Boyd, J.Prereduction radiographs in clinically evident anterior shoulder dislocation. Am J Emerg Med 1999;17:653–8.Google Scholar
12.Hendey, GW, Kinlaw, K.Clinically significant abnormalities in postreduction radiographs after anterior shoulder dislocation. Ann Emerg Med 1996;28:399–402.Google Scholar
13.Anis, AH, Stiell, IG, Stewart, DG, et al.Cost-effectiveness analysis of the Ottawa Ankle Rules. Ann Emerg Med 1995;26:422–8.CrossRefGoogle ScholarPubMed
14.Taylor, DC, Arciero, RA.Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306–11.CrossRefGoogle ScholarPubMed
15.Breiman, L.Classification and regression trees. Wadsworth statistics/probability series. New York (NY): Chapman and Hall;1993. p. 358.Google Scholar
16.Carley, S, Dosman, S, Jones, SR, et al.Simple nomograms to calculate sample size in diagnostic studies. Emerg Med J 2005;22:180–1.Google Scholar
17.Beeson, MS.Complications of shoulder dislocation. Am J Emerg Med 1999;17:288–95.CrossRefGoogle ScholarPubMed
18.Blake, R, Hoffman, J.Emergency department evaluation and treatment of the shoulder and humerus. Emerg Med Clin North Am 1999;17:859–76.Google Scholar
19.Perron, AD, Ingerski, MS, Brady, WJ, et al.Acute complications associated with shoulder dislocation at an academic emergency department. J Emerg Med 2003;24:141–5.CrossRefGoogle ScholarPubMed
20.Hersche, O, Gerber, C.Iatrogenic displacement of fracture-1 dislocations of the shoulder. A report of seven cases. J Bone Joint Surg Br 1994;76:30–3.CrossRefGoogle Scholar
21.Pasila, M, Jaroma, H, Kiviluoto, O, et al.Early complications of primary shoulde dislocations. Acta Orthop Scand 1978;49:260–3.Google Scholar
22.Rowe, CR.Prognosis in dislocations of the shoulder. J Bone JointSurg Am 1956;38–A:957–77.Google Scholar
23.Lind, T, Kroner, K, Jensen, J.The epidemiology of fractures of the proximal humerus. Arch Orthop Trauma Surg 1989;108:285–7.Google Scholar
24.Nordqvist, A, Petersson, CJ.Shoulder injuries common in alcoholics. Analysis of 413 injuries. Acta Orthop Scand 1996;67:364–6.Google Scholar
25.Pasila, M, Kiviluoto, O, Jaroma , H, et al.Recovery from primary shoulder dislocation and its complications. Acta Orthop Scand 1980;51:257–62.Google Scholar
26.Stiell, IG, Wells, GA, Vandemheen, K, et al.The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357:1391–6.Google Scholar