Multicenter Comparison of Two Clinical Decision Rules for the Use of Radiography in Acute, High-Risk Knee Injuries☆,☆☆,★
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INTRODUCTION
Patients with acute knee injuries are common in the ED, accounting for up to 1 million visits annually.1 Previous studies have shown that up to 85% of patients undergo radiography2; however, in only 6% to 12%3, 4, 5 are fractures actually identified. Despite this low incidence, it is common practice in many institutions to perform radiography in all traumatic knee injuries.
This conservative approach to the assessment of the knee results in many unnecessary radiographs, meaning potential excess
MATERIALS AND METHODS
We designed a prospective, blinded, multicenter validation-and-comparison trial in the EDs of three teaching hospitals: Mercy Hospital of Pittsburgh, the University of Pittsburgh Medical Center, and MetroHealth Medical Center in Cleveland. The study protocol was approved by the institutional review boards of all three hospitals. The requirement for written informed consent was waived because no intervention was performed and the data were kept confidential.
The study population was a convenience
RESULTS
Overall, 934 patients (ages range, 6 to 96 years) were enrolled into the study over an 18-month period. Table 1 lists the ED diagnoses of all patients.
Contusions, sprains, and strains accounted for 77% of the total diagnoses. We noted 103 fractures (11%); tibial plateau and patellar fractures were the most common (Table 2).
Location No. (%) Tibial plateau 41 (40) Patella 36 (34) Femoral condyle 11 (11) Fibular head 10 (10) Tibial spine 4 (4) Salter II 1 (1)
For the PGH rule, we
DISCUSSION
Clinical decision rules (prediction rules) reduce the uncertainty in patient care for both diagnostic and therapeutic decisionmaking. Methodologic standards for the development and testing of clinical decision rules are well-established.7, 10 Several clinical decision rules for the use of radiography in knee injuries have been developed in the last several years.3, 4, 5, 11, 12 The two rules with the largest validation cohorts were compared in our study. Both clinical decision rules were highly
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Cited by (0)
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From the University of Florida Health Science Center, Jacksonville, FL*; the University of Pittsburgh Medical Center‡ and Mercy Hospital,§ Pittsburgh, PA; and MetroHealth Medical Center, Cleveland, OH.II
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Reprint no. 47/1/90757
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Address for reprints: David C Seaberg, MD, Division of Emergency Medicine, University of Florida Health Science Center, 655 West Eighth Street, Jacksonville, FL 32209