![]() Look at the Gilula lines 1, 2, and 3 in that order (See picture below that show Gilula lines) The right shows <2/3rd of lunate articulating with the distal radius which means there is ulnar subluxation and some pretty serious ligamentous injury (Credit: Llyas JAAOS, 2008). Look at the radiocarpal joint, 2/3rds of the lunate should articulate with the distal radius Look at distal radioulnar joint (DRUJ), widening of the DRUJ can communicate instability (Remember the important angles of what is acceptable) Look at cortices when outlining then look at medulla for any abnormalities AP view: Work your way proximal to distal.Go back and systematically go through the images in each view Use the most straightforward and correct answer.Īfter you have established the obvious. Look for obvious injuries and comment on them. If you aren’t sure, just say 3 views of a R wrist… for example Say what views your are looking at (AP, Lateral, Oblique) If applicable verify patient, laterality, and quality of xrays Always be on the look out for being more efficient and making things better. That’s fine! Develop a system that does work. "We look forward to conducting our implementation study.There are many ways to do this. "Our results show that unnecessary wrist imaging in children can be prevented - which will reduce radiation exposure to these patients, healthcare costs, and workflow inefficiencies," Slaar told. They plan to conduct another study that will evaluate the effect of the protocol on the number of x-rays, emergency department wait times, and healthcare costs, with the decision tool available as a smartphone application. In any case, the study demonstrates that this type of clinical protocol is useful, the researchers concluded. "Since we aimed to reduce the number of requested wrist radiographs, a threshold compromise between missed fractures and reduction of radiographs was chosen." "We could have generated a higher specificity by using another threshold, but this would have led to a decrease in the sensitivity and thus an increase of missed fractures," they wrote. And the protocol's specificity was fairly low, at 37.3%. The protocol also could have reduced healthcare costs by 96,000 euros ($108,830 U.S.) per 100,000 children annually.Īs for the clinical decision model's limitations, it would have missed 4% of the fractures in the validation cohort - although the treatment and prognosis would not have been influenced by a missed or delayed diagnosis, according to Slaar and colleagues. In 2009, 8,930 per 100,000 children presented with a wrist injury using the protocol would have reduced the number of requested x-rays by almost 2,000 per 100,000, or 22%, the authors wrote. The six-variable clinical model had a specificity of 95.9% for detecting distal forearm fractures. Left, posteroanterior view right, lateral view. By group, 194 children in the protocol development cohort (47.5%) and 170 in the validation group (44.9%) had a distal forearm fracture.īuckle fracture of the distal radius in a 9-year-old girl. Of the total number of children included in the study, 364 had a distal forearm fracture (46.3%) and 423 did not (53.7%). Tenderness at palpation of the anatomical snuffbox (the triangular depression at the wrist when the thumb is fully extended).Slaar's team included six variables in its decision model, which it called the Amsterdam Pediatric Wrist Rules: They were divided into two groups: one served as the cohort for the development of the clinical protocol (408 patients) and the other as the cohort for the protocol's validation (379 patients). The study included 787 children who received x-rays for wrist trauma between April 2011 and April 2014. "So for this study, we sought to develop and test a clinical decision rule that would help physicians decide whether an x-ray is really needed." "In our previous work, we found that half of the pediatric patients who received x-ray for blunt trauma of the wrist had normal radiographs," Slaar told via email. But no guidelines exist to help emergency physicians determine when x-ray imaging of wrist trauma is appropriate, and in a previous study, Slaar and colleagues found that only 51% of x-rays acquired for this reason actually showed a fracture ( Pediatr Radiol, August 23, 2015). in part because more x-rays are being performed to diagnose the injury. The rise in incidence has sparked a surge in cost - to the tune of more than $2 billion per year in the U.S. Dr. Annelie Slaar from the University of Amsterdam.
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