�������� ����� ��

Determination of radiography requirement in wrist trauma

Suha Turkmen MD, Aysegul Cansu MD, Yunus Karaca MD, MehmetEmre Baki MD, Oguz Eroglu MD, Ozgur Tatli MD, Mucahit Gunaydin MD,Ercument Beyhun MD, Abdulkadir Gunduz MD, Suleyman Turedi MD

PII: S0735-6757(15)00483-0DOI: doi: 10.1016/j.ajem.2015.06.011Reference: YAJEM 55061

To appear in: American Journal of Emergency Medicine

Received date: 10 March 2015Revised date: 10 June 2015Accepted date: 10 June 2015

Please cite this article as: Turkmen Suha, Cansu Aysegul, Karaca Yunus, Baki MehmetEmre, Eroglu Oguz, Tatli Ozgur, Gunaydin Mucahit, Beyhun Ercument, Gunduz Ab-dulkadir, Turedi Suleyman, Determination of radiography requirement in wrist trauma,American Journal of Emergency Medicine (2015), doi: 10.1016/j.ajem.2015.06.011

This is a PDF file of an unedited manuscript that has been accepted for publication.As a service to our customers we are providing this early version of the manuscript.The manuscript will undergo copyediting, typesetting, and review of the resulting proofbefore it is published in its final form. Please note that during the production processerrors may be discovered which could affect the content, and all legal disclaimers thatapply to the journal pertain.

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT

Determination of radiography requirement in wrist trauma

Suha Turkmen, Aysegul Cansu, Yunus Karaca, Mehmet Emre Baki, Oguz Eroglu, Ozgur

Tatli, Mucahit Gunaydin, Ercument Beyhun, Abdulkadir Gunduz, Suleyman Turedi

1. Associate professor, MD, Karadeniz Technical University, Faculty of

Medicine, Department of Emergency Medicine, Trabzon, TURKEY

2. Assistant professor, MD, Karadeniz Technical University, Faculty of

Medicine, Department of Radiology, Trabzon, TURKEY

3. Assistant professor, MD, Karadeniz Technical University, Faculty of

Medicine, Department of Emergency Medicine, Trabzon, TURKEY

4. Assistant professor, MD, Karadeniz Technical University, Faculty of

Medicine, Department of Orthopaedics and Traumatology, Trabzon,

TURKEY

5. Assistant professor, MD, Kırıkkale University, Faculty of Medicine,

Department of Emergency Medicine, Kırıkkale, TURKEY

6. Physician, MD, Kanuni Training and Research Hospital, Department of

Emergency Medicine, Trabzon, TURKEY

7. Assistant professor, MD, Giresun University, Faculty of Medicine,

Department of Emergency Medicine, Giresun, TURKEY

8. Associate professor, MD, Karadeniz Technical University, Faculty of

Medicine, Department of Public Health, Trabzon, TURKEY

9. Associate professor, MD, Karadeniz Technical University, Faculty of

Medicine, Department of Emergency Medicine, Trabzon, TURKEY

10.Associate professor, MD, Karadeniz Technical University, Faculty of

Medicine, Department of Emergency Medicine, Trabzon, TURKEY

Corresponding author:

Suha Turkmen

Karadeniz Teknik Universitesi

Tip Fakultesi Acil Tip AD

61080 Trabzon/Turkey

Email: drsuhaturkmen@hotmail.com

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPTDetermination of the requirement for radiology in wrist trauma

ABSTRACT

Objectives

The purpose of this study was to evaluate predetermined physical examination and

function tests recommended to identify severe injury among patients presenting

with wrist injury to the emergency department and to establish a reliable clinical

decision rule capable of determining the need for radiography in wrist injuries.

Materials and Methods

This was a multicenter prospective derivation study of wrist injuries. All patients

were assessed in terms of mechanism of trauma, inspection findings, heart rate,

sensitivity at palpation, presence of pain with active movement, grasp strength and

functional tests using an examination form under main headings. Sensitivity,

specificity and positive and negative predictive values were expressed for each sign

and each examination finding.

Results

One hundred nineteen adult patients were enrolled during the 6-month study

period. Fracture was identified in 24.3% (n=29). Presence of pain on the radial

deviation, dorsal flexion, distal radioulnar drawer and axial compression tests

exhibited high sensitivity (82.8, 89.7, 82.8 and 86.2, respectively) and high negative

predictive values (88.6, 81.3, 87.5 and 93.6, respectively) for wrist fracture.

Sensitivity of 96.6% was observed when these four tests were evaluated together.

Conclusions

The presence of one of these examination findings increases the likelihood of

fracture and is adequate to recommend wrist radiography. In addition, there is a

strong possibility of x-ray being unnecessary if all four of tests are negative in

patients presenting with wrist injury, potentially preventing many non-essential x-

rays being performed.

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT

Key words: Wrist injury, radiography, clinical decision rule

INTRODUCTION

Background

Wrist injuries are one of the most common traumatic presentations to the

emergency department due to trauma (1). Radiography is frequently required in

diagnosing these patients, but unnecessary radiological investigation results in

increased costs, exposure to radiation and prolonged patient waiting times.

Currently, there is no algorithm available for to guide clinicians in the use of

radiograph for patients presenting to the emergency department with wrist injury.

The majority of radiographs requested in wrist injuries do not demonstrate any

pathology. A significant number of radiographs are inadequate in that they are

unable to identify some bone pathologies and most ligamentous lesions. In addition,

it is not clear that radiograph results change the treatment plan for most patients.

Importance

For these reasons, a reliable and generally applicable clinical decision rule to

determine the need for radiography in patients presenting to the emergency

department with wrist injury is desirable (2). Previous studies performed for this

purpose have reported that some physiological examination findings and functional

tests can be used to identify patients with wrist injury who do require radiography.

However, no definitive conclusion has been reached because of significant

limitations primarily insufficient patient numbers (3).

Goals of This Investigation

The purpose of this study was to assess the sensitivity and specificity of

physical examinations findings and functional tests to establish a reliable and widely

useable clinical decision rule to determine the necessity of radiography in wrist

trauma.

MATERIAL AND METHODS

Study design and setting

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT This research is a multicenter prospective derivation study of wrist injuries.

Patients older than fifteen presenting with wrist injury to three hospitals in

Trabzon, Turkey, were included in the study. One is a university hospital where

emergency medicine residents are trained, the second is a training and research

hospital where emergency medicine residents are trained and the third is a public

hospital. The study was performed between June 1, 2013 and January 1, 2014,

following approval by the local ethics committee (Approval no: 2013/3). The study

was conducted and reported in accordance with Green principles (4).

Selection of Participants

Patients older than fifteen presenting to the emergency department within

the first 24 hours of wrist injury and giving their consent were enrolled. For all

participants younger than 18 years, both the child’s and parental consents were

obtained. Patients with multiple injuries, altered consciousness, neuromuscular

disease, ipsilateral elbow or forearm trauma, open fracture or distracting injury

were excluded. Triage was performed and analgesia was offered. All participants

were examined and an examination form was completed for each patient. All

patients were assessed for mechanism of trauma, inspection findings, radial pulse,

tenderness on palpation, presence of pain with active movement, grasp strength and

in terms of functional tests.

Methods and Measurements

Physicians in the participating emergency departments were given standard

training in each wrist examination technique. To maintain consistency in

examination, the examination techniques were illustrated on the examination form.

Physical examination findings and clinical findings from functional tests were

evaluated in terms of their potential use as a marker of the requirement for x-ray.

Physicians were asked to assess patients by inspection for swelling in the distal

radius and visible deformity. They were asked to use palpation to determine

presence of tenderness in predetermined locations (distal radius, snuffbox, radial

styloid, ulnar styloid and Lister’s tubercle) and to evaluate radial artery pulse. In

addition, they were asked to assess whether pain was present with active

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPTmovements (dorsal flexion, palmar flexion, supination, pronation, ulnar deviation

and radial deviation). The examination concluded with the application of the distal

radioulnar drawer test and axial compression test.

Two-dimensional radiography (anteroposterior and lateral) was performed

on all patients in the study, independently of the physical evaluation results. An

experienced radiologist blind to the examination findings reported the X-rays. In

cases in which the radiologist was uncertain about the presence or absence of a

fracture, further evaluation was performed via CT or repeat x-ray 1 week later and

reported by the same radiologist. Patients with a fracture identified on the first x-

ray and initially questionable cases in which fracture was determined on the basis of

CT or repeat x-ray 1 week later were recorded as fracture positive.

Outcomes

Radiographic documentation of bony injury of the wrist was the primary

endpoint for evaluating the validity of the proposed criteria to determine the

predictive value of these criteria in establishing a clinical decision tool for the

management of patients with wrist injury. The predictive value of each criterion was

evaluated independently. The combination of findings with the highest predictive

values for fracture were assessed together.

Analysis

Statistical analysis was performed on SPSS 13.0 software. Descriptive

characteristics (side affected, mechanism of trauma, dominant hand) were

expressed as numbers and percentages. Sensitivity, specificity, and positive and

negative predictive values for all symptoms and examination findings were

expressed as percentages. Incidences of symptoms between fracture and no fracture

groups were analyzed using the Pearson chi square and Fisher’s exact tests.

RESULTS

Characteristics of study subjects

A total of 467 eligible trauma patients presented to the participating EDs

during the study period. 220 patients with multiple injuries, 78 patients with

ipsilateral elbow or forearm injuries, 15 patients with open fracture or distracting

injuries were excluded. 35 patients did not consent to participate. 119 patients were

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPTenrolled during the 6-month study period. Age range was 16-65 years (mean 27).

Sixty-one percent of the patients were men and 39% women. Falling on an

outstretched hand accounted for 56.3% of injuries, sports injuries for 24.4%, motor

vehicle accidents for 5.9% and other causes for 13.4%. The right hand was

dominant in the great majority of patients (91.8%) and the right wrist was the more

commonly affected side at 51.3%. Fracture was identified in 24.3% of patients

(n=29). Pathological findings for the 29 patients with fracture identified at

radiography are shown in Table 1.

Main results

Physical examination findings and functional test results for patients with or

without identified fracture are shown in Table 2. Predictive values of clinical

findings are shown in Table 2. Of the clinical findings, pain on dorsal flexion had the

highest sensitivity at 89.7% of patients with fracture. The examination finding with

the second highest sensitivity was the axial compression test at 86.2%. Sensitivity of

82.8% was determined for the distal radioulnar drawer test and radial deviation

test. Of the wrist examination techniques, presence of pain on the radial deviation

test, dorsal flexion, the distal radioulnar drawer test and the axial compression test

exhibited high sensitivity (82.8, 89.7, 82.8 and 86.2, respectively) and high negative

predictive values (88.6, 81.3, 87.5 and 93.6, respectively) for wrist fracture.

Sensitivity reached the desired levels (96.6%; and 95% CI 80.4-99.8), in other words

nearly all cases of fracture were identified, when these four simple, practical and

easy to remember tests were performed together. Specificity was observed at a low

level (12.2%; and 95% CI 6.6-21.2). The negative predictive value for the four tests

in combination is 91.7% (95% CI 59.8-99.6). These four examination findings were

negative in only one patient with wrist fracture. Examination of that patient

revealed a nondisplaced fracture of the ulna styloid process. The patient reported

previous trauma to that region, but it was impossible to determine whether this

finding on wrist x-ray was old or new.

DISCUSSION

Physical examination findings with high sensitivity and high negative

predictive values in subjects with wrist injury were the presence or absence of pain

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPTon the radial deviation test, the dorsal flexion test, the distal radioulnar drawer test

and the axial compression test. The presence of pain on any one of these

examination findings increases the likelihood of fracture and is sufficient to

recommend wrist x-ray. In the event that these four findings are negative, it may be

appropriate to recommend that wrist x-ray can be avoided. The results indicate that

if all four tests are negative, the combined sensitivity is 96.6%. The Ottawa Ankle

Rules clinical decision tool has a sensitivity of almost 100% and a modest specificity,

and is reported to reduce the number of ankle x-rays by 30-40% (5). It is reasonable

to suggest that a decision tool developed from our findings would have a similar

impact on reducing wrist x-ray.

One study intended to identify patients with wrist injuries requiring x-ray was

that by Cevik et al. Fifty-five patients with wrist injuries were enrolled, and fracture

was determined in 35, or 63.6%. Cevik evaluated nine examination findings and

reported that five of these were significant (3). The five principal physical findings

most associated with fracture, in descending order of sensitivity, were pain on

active motion, localized tenderness, pain on passive motion, pain on grip and pain

on supination. The study suggests that these five examination findings can identify

patients requiring x-ray without using more complex examination techniques.

Calvo-Lorenzo et al. performed another study for the same purpose, recommending

a staged assessment (6). Presence of any one of age 35 or more, edema in the

dorsum of the wrist, limitation in supination or active radial deviation and pain or

instability on performing the distal radioulnar drawer test were sufficient to require

x-ray. However, the inclusion of age greater than 35 years as an independent risk

factor may result in a large patient population being x-rayed unnecessarily.

Assessment in the second stage of that study involves presence or absence of edema

in the wrist. Edema is a significant finding after trauma and development is known

to be time-dependent. Sufficient time may not have elapsed for edema to develop in

a patient presenting in the early period. In addition, soft tissue injury with no

fracture can also lead to edema. Functional tests have been described as complex,

with low repeatability and reliability (7). Our findings, however, show that these

tests are the most valuable physical examination methods in wrist assessment.

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPTThe comprehensive study of wrist injury published by Van der Brand et al.

suggests that there is no need for a clinical decision rule in patients with wrist

trauma, because of the high proportion of fractures in wrist injury (8). Van der

Brand recommends radiography in all wrist trauma patients. The study has several

limitations, the most important being that they were not able to reliably assess

physical examination findings in all patients because of the retrospective study

design.

The most important limitation of our study is the small case number. The

main reason for this limitation is that we considered a number of physical

examination findings, thus the examination form is very broad and impractical.

Calvo-Lorenzo et al. realized that the number of participants would be low for the

same reason and elected to reduce the parameters to be investigated in their study

(6). The current study should be considered preliminary work. We planned to

conclude the study with this limited number of patients but we intend to carry out a

future study with a more practical examination form in the light of these findings

and those of previous studies. The second limitation of this study is the inability to

deterimine inter-rater reliability in that only one senior radiologist interpreted the

x-rays. A second radiologist or emergency physician did not confirm the results.

Thus, it is possible that there are unintentional faults in x-ray interpretations. In

addition, the presence or absence of radial artery pulsation could be added as a fifth

finding because of its very high sensitivity and high NPV. But, very few patients had

negative radial artery pulsation so no definitive conclusion can be drawn from such

limited data.

CONCLUSIONS

Patient evaluation using the four examination methods recommended in this

study provides valuable information about wrist bone status and effectively predicts

whether x-ray is required. According to our results, one positive finding on the wrist

examination techniques (radial deviation test, dorsal flexion test, distal radioulnar

drawer test and axial compression test) in a patient presenting with wrist injury is

sufficient to recommend wrist radiography. If all four findings are negative, wrist

radiography is not indicated.

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPTAcknowledgement: We thank Diane Williamson, MD, for her contributions to the

study design and final manuscript of this project.

REFERENCES

1. Owen RA, Melton LJ 3rd, Johnson KA, Ilstrup DM, Riggs BL. Incidence of Colles'

fracture in a North American community. Am J Public Health. 1982;72:605-7.

2. Slaar A, Bentohami A, Kessels J, Bijlsma TS, van Dijkman BA, Maas M, et al. The

role of plain radiography in paediatric wrist trauma. Insights Imaging. 2012;3:513-

7.

3. Cevik AA, Gunal I, Manisali M, Yanturali S, Atilla R, Pekdemir M, et al. Evaluation of

physical findings in acute wrist trauma in the emergency department. Ulus Travma

Acil Cerrahi Derg. 2003;9:257-61.

4. Green SM, Schriger DL, Yealy DM. Methodologic Standards for Interpreting

Clinical Decision Rules in Emergency Medicine: 2014 Update. Ann Emerg Med.

2014;64:286-91.

5. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle

rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ.

2003;22;326(7386):417.

6. Calvo-Lorenzo I, Martínez-de la Llana O, Blanco-Santiago D, Zabala-Echenagusia J,

Laita-Legarreta A, Azores-Galeano X. Would it be possible to develop a set of Ottawa

wrist rules to facilitate clinical decision making? Rev. esp. cir. ortop. traumatol.

2008;52:315-21

7. Esberger DA. What value the scaphoid compression test? J Hand Surg Br.

1994;19B:748-9.

8. van den Brand CL, van Leerdam RH, van Ufford JH, Rhemrev SJ. Is there a need for

a clinical decision rule in blunt wrist trauma? Injury. 2013;44:1615-9.

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPTTable 1: The details of patients who has fracture on wrist radiograph

Radiologic Diagnosis Number of Patients Percentage (%) Distal radius fracture 16 55.1 Ulnar styloid fracture 5 17.2 Distal radius + ulna fracture

4 13.7

Distal ulna fracture 2 6.8 Carpal bone fracture 2 6.8 Total 29 100

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPTTable 2: Predictive values of clinical findings

Findings Fracture

(+)

(n=29)

Fracture

(-)

(n=90)

P value

Chisquare

Fr

forecast

(%-

median)

Sensitivity

% (95%CI)

Specificity

% (95%CI)

PPV

%

(95%CI)

NPV

%

(95%CI)

Inspection

Distal radial edema + 18 25 0.001 70 62.1 (42.4 – 78.7)

72.2 (61.6 – 80.9)

41.9 (27.4 – 57.8)

85.5(75.2-92.2)

- 11 65 10

Anatomic snuffbox edema + 16 16 0.000 85 55.2 (35.9 – 73.0)

82.2 (72.4 – 89.2)

50.0 (32.3 – 67.8)

85.1 (75.4 – 91.5)

- 13 74 10

Deformity + 18 6 0.000 100 62.1 (42.4-78.7)

93.3 (85.5-97.2)

75.0 (52.9-89.4)

88.4 (79.8-93.8)

- 11 84 10

Palpation

Radial artery pulsation + 28 86 1.000 30 96.6 (80.4-99.8)

4.4 (1.4-11.6)

24.6 (17.2-33.7)

80.0 (29.9-99.0)

- 1 4 70

Pain with palpation

Distal radius + 22 67 0.878 30 75.9 (76.1-89.0)

25.6 (17.2-36.0)

24.7 (16.5-35.2)

76.7 (57.3-89.4)

- 7 23 20

Distal ulna + 14 18 0.003 55 48.3 (29.9-67.1)

80.0 (70.0-87.4)

43.8(26.8-62.1)

82.8 (72.8-89.7)

- 15 72 10

Anatomic snuffbox + 15 25 0.018 70 51.7 (32.9-70.1)

72.2 (61.6-80.9)

37.5 (23.2-54.2)

82.3 (71.7-89.6)

- 14 65 10

Radial styloid + 19 47 0.210 50 65.5 (45.7-81.4)

47.8 (37.2-58.5)

28.8 (18.6-41.4)

81.1 (67.6-90.1)

- 10 43 10

Ulnar styloid + 12 11 0.001 60 41.4 (24.1-60.9)

87.8 (78.8-93.5)

30.8 (17.6-47.7)

82.3 (72.9-89.1)

- 17 79 20

Lister's tubercule + 18 21 0.000 80 62.1 (42.4-87.7)

76.7 (66.4-84.7)

46.2 (30.4-62.6)

86.3 (76.3-92.6)

- 11 69 10

Pain with active movement

Dorsal flexion + 26 77 0.758 30 89.7(71.5-97.3)

14.4 (8.2-23.8)

25.2 (17.4-34.9)

81.3 (53.7-95.0)

- 3 13 5

Palmar flexion + 22 31 0.000 75 75.9 (56.1-89.0)

65.6 (54.7-75.1)

41.5 (28.4-55.8)

89.4 (78.8-95.3)

- 7 59 10

Supination + 22 25 0.000 80 75.9 (56.1-89.0)

72.2 (61.6-80.9)

46.8 (32.4-61.8)

90.3 (80.4-95.7)

- 7 65 10

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPTPronation + 22 21 0.000 80 75.9 (56.1-

89.0) 76.7 (66.4-84.7)

51.2 (35.7-66.4)

90.8 (81.4-95.9)

- 7 69 10

Ulnar deviation + 19 15 0.000 77.5 65.5 (45.7-81.4)

83.3 (73.7-90.1)

55.9 (38.1-72.4)

88.2 (79.0-93.9)

- 10 75 10

Radial deviation + 24 51 0.011 50 82.8 (63.5-93.5)

43.3 (33.1-54.2)

32.0 (22.0-43.9)

88.6 (74.7-95.7)

- 5 39 10

Functional tests

Positive distal radioulnar

drawer test

+ 24 55 0.032 50 82.8 (63.5-93.5)

38.9 (29.0-49.8)

30.4 (20.8-41.9)

87.5 (72.4-95.3)

- 5 35 5

Axial compression + 25 32 0.000 70 86.2 (67.4-95.5)

64.4 (53.6-74.1)

43.9 (31.0-57.6)

93.6 (83.5-97.9)

- 4 58 10