Clinical decision rule for knee radiographs

doi:10.1016/0735-6757(94)90274-7

The American Journal of Emergency Medicine

Volume 12, Issue 5, September 1994, Pages 541-543

https://doi.org/10.1016/0735-6757(94)90274-7 Get rights and content

Abstract

The objective of this study was to develop a decision rule for ordering x-rays in knee injuries. Phase I was a retrospective chart review of 201 consecutive patients receiving knee radiographs in the emergency department in a 10-month period. Logistic regression was performed on 11 clinical indicators to develop a clinical decision rule. Phase II was a prospective validation study on 133 consecutive patients with knee injuries. All patients received radiographs to validate the decision rule. Sensitivity, specificity, and misclassification rate were calculated. Logistic regression analysis found that a fall or blunt trauma mechanism yielded a logistic regression sensitivity of 92%, specificity of 57%, with a false-negative rate of 0.9%. The addition of inability to ambulate and age (younger than 12 or older than 50 years of age) yielded a sensitivity of 92% with a specificity of 63%. The prospective study found the combination of fall or blunt trauma with either inability to ambulate or age (younger than 12 to older than 50 years of age) was 100% sensitive, with a specificity of 79%. The misclassification rate was 20%. Using this decision rule, the number of x-rays taken could have been reduced by 78%. A larger multicenter validation study of this knee radiograph decision rule is needed before widespread clinical usage.

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Traumatic injuries to the knee are extremely common but only rarely severe, the vast majority being benign sprains or contusions.
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Radiographs remain the firstline imaging, CT being indicated to evaluate an articular fracture or to detect articular loose fragments.
Joint effusion is reliable indirect sign of injury: it can be either a hemarthrosis reflecting, at least, a tear of articular soft tissue (ligament, meniscus) or a lipohemarthrosis that reveals an articular fracture.
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Routinely obtaining adjacent joint radiographs when evaluating patients with ankle fractures may be of limited clinical utility and an unnecessary burden, particularly in the absence of clinical suspicion for concomitant injuries.
One thousand, three hundred and seventy patients who sustained ankle fractures over a 5-year period presenting to two level 1 trauma centers were identified. Medical records were retrospectively reviewed for demographics, physical examination findings, and radiographic information. Analyses included descriptive statistics along with sensitivity and predictive value calculations for the presence of adjacent joint fracture.
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The addition of adjacent joint imaging for the evaluation of patients sustaining ankle fractures is low yield. As such, patient history, physical examination, and clinical suspicion should direct the need for additional X-rays.
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^☆: Presented at the Society for Academic Emergency Medicine Annual Meeting, San Francisco, CA, May 1993.

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Brief reportClinical decision rule for knee radiographs☆

Abstract

Ann Emerg Med

Ann Emerg Med

Am Emerg Med

Routine radiographs in acute knee distortions

Orthopedics

Vaerdien af primaer rontgenundersogelse ved klinisk mistanke om meniskog/eller ligamentlaesion

Ugeskr Laeger

The role of knee radiographs in the emergency department: A prospective study

Ann Emerg Med

Guidelines for selective radiological assessment of inversion ankle injuries

Br Med J

Brief report
Clinical decision rule for knee radiographs☆