190: Pediatric Elbow Fractures: Diagnostic Accuracy of the Combination of Point Tenderness with the Elbow Extension Test
Notice bibliographique
Résumé
Elbow injuries are common in children and adolescents accounting for 3% of total emergency room visits. The elbow extension test alone has not been shown to reliably exclude the presence of fractures in pediatrics, thereby most children are referred for a diagnostic elbow x-ray. Determine whether the combination of point tenderness and the elbow extension test improves the diagnostic accuracy for pediatric elbow injuries requiring immobilization. Prospective observational study of patients less than 18 years of age with acute elbow injuries presenting to a tertiary care pediatric emergency department. Patients were managed according to the discretion of the treating physician with imaging and immobilization. The index test was defined as positive if elbow tenderness was present at one of five locations or had incomplete extension of the injured elbow. The assessment was performed by attending physicians or senior residents (≥PGY-3) and inter-observer reliability was assessed on ∼10%. The radiologist's report of the radiographs or, for those without radiographs, a diagnosis of a missed fracture after a structured follow-up phone call one week post-injury was used as the reference standard for the diagnosis of a fracture and/or elbow effusion. A total of 2331 patients were screened with elbow injuries; 1380 excluded (66% pulled elbow, 22% referred in, 7% obvious deformity, 2% uncooperative with exam, 2% polytrauma and 1% other). Amongst the 951 eligible patients, a research assistant recruited a convenience sample of 43%. The mean age was 8.8±4.1 years and 52% male. Of the 334 recruited patients, 97.9% had radiographs and 186 (57%) were diagnosed with an elbow injury requiring immobilization (75.3% had a fracture, 24.7% an isolated effusion). A positive index test was present in 302 (90.4%) and had a sensitivity and specificity of 95.6% (95% CI 91.0% to 98.1%) and 16.9% (95% CI 11.1% to 24.7%), respectively. In comparison, elbow extension alone had a sensitivity and specificity of 82.1% (95% CI 75.1% to 87.5%) and 62.3% (95% CI 53.3% to 70.5%), respectively. Inter-observer reliability assessed on ∼10% was excellent (kappa of 1 for index test and 0.86±0.09 for elbow extension test). Diagnostic accuracy for elbow fractures as the reference standard (ie, not isolated effusions) revealed a sensitivity of 99.2% (95% CI 97.7% to 100.7%) and specificity 16.3% (95% CI 10.5% to 22.0%). Subgroup analysis revealed similar trends for children younger than three years of age. The addition of point tenderness to the elbow extension test improves the sensitivity for the detection of elbow injuries requiring imaging and immobilization, but at a significant decrement of specificity. Future studies are needed to determine how to improve the detection of injuries requiring immobilization from those who can forego any further diagnostic tests.
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Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,002 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,000 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».