The Quebec shoulder dislocation rule is a recently derived clinical decision rule to guide physicians on the selective use of radiography in patients with shoulder dislocation. The aim of this studywas to validate the Quebec shoulder dislocation rule.

This was a secondary analysis of data collected in a retrospective cohort study. All patients presenting to the emergency department (ED) between January 1, 2003, and October 31, 2008, with a diagnosis of shoulder dislocation or fracture-dislocation were identified from ED management databases. Data collected included demographics, mechanism of injury, and presence of fracture. The outcome of interest was predictive performance of the Quebec shoulder dislocation rule for patients aged under 40 years on this cohort. Data analysis is descriptive.

Of the 346 patients identified, 196 were aged under 40 years, and 174 (89%) were male; the median age was 25 years (interquartile range 21–29 years), and 58 were recurrent dislocations. One hundred sixteen patients (59%) met the Quebec high-risk criteria, and 80 (41%) were classified as low risk. In the 196 patients aged less than 40 years, 12 fractures as defined were identified (6%). When applied to this cohort, the Quebec clinical decision rule had a sensitivity of 0.42 (95% CI 0.16–0.71), a specificity of 0.40 (95% CI 0.33–0.47), and a negative predictive value of 0.91 (95% CI 0.82–0.96).

The Quebec shoulder dislocation rule had poor sensitivity for clinically significant fractures associated with shoulder dislocations in young patients (aged 16–39 years) presenting to an Australian emergency department. Its use cannot be recommended.

Current recommended treatment for middle-third clavicle fractures is limited to the use of ice, analgesics, a sling, and rest. Radiography for these fractures would be superfluous if physicians could accurately identify them by clinical examination alone. The primary purpose of this study was to determine whether emergency physicians can accurately diagnose clavicle fractures, and whether they can differentiate middle-third fractures from medial- or lateral-third fractures by clinical assessment alone.

We enrolled a convenience sample of patients who presented to our rural emergency department with possible clavicle fracture between Nov. 1, 2001, and Apr. 30, 2002. Prior to viewing radiographs, physicians scored their clinical certainty of diagnosis on a 10-cm visual analogue scale. When certain of fracture, physicians determined the location of the fracture, the nature of the fracture and their hypothetical comfort in treating the injury without radiography.

In 51 of 77 enrolled patients (66%; 95% confidence interval [CI], 54.6%–76.6%), treating physicians were certain of the diagnosis of clavicle fracture prior to radiography. In these 51 cases, radiography revealed a fracture in 50 cases (98.0%; 95%CI, 89.6%–99.9%). The physicians were 100% accurate for 4 fractures clinically identified as lateral-third fractures (95% CI, 39.7%–100%) and for 41 fractures identified as middle-third fractures (95% CI, 91.4%–100%). They were correct on only 1 of 5 injuries (20%; 95% CI: 1%–72%) they clinically identified as medial-third fractures. Despite high clinical accuracy with middle-third fractures, they stated in 27 of 42 cases (64%; 95%CI, 48.0%–78.5%) that they would have been uncomfortable treating the patient without a radiograph.

This study provides evidence that experienced emergency physicians are highly accurate when they are clinically certain of clavicle fracture. Further, when emergency physicians do clinically diagnose clavicle fracture, they can accurately identify the patient subgroup that will be responsive to conservative treatment. Routine radiography of obvious middle-third clavicle fractures does not appear to improve diagnostic accuracy or treatment decisions.

Research has demonstrated that experienced emergency physicians can identify a subgroup of patients with shoulder dislocation for whom pre-reduction radiographs do not alter patient management. Based on that research, a treatment guideline for the selective elimination of pre-reduction radiographs in clinically evident cases of anterior shoulder dislocation was developed and implemented. The primary objective of this study was to prospectively determine whether the treatment guideline safely eliminates unnecessary radiographs.

We enrolled a convenience sample of patients who presented to our rural emergency department with possible shoulder dislocation between November 2000 and April 2001. Physicians scored their level of clinical diagnostic certainty on a 10-cm visual analogue scale prior to viewing pre-reduction radiographs (if obtained). Data were collected on clinical scoring and evaluation, compliance with the guideline, and outcomes.

A total of 63 patients were enrolled, ranging in age from 17 to 79 years (mean = 33); 87.3% were male. Emergency physicians were certain of shoulder dislocation in 59 (93.7%) patients (95% CI, 84.5%–98.2%) and complied with the treatment guideline in 52 patients (82.5%). Most deviations from the treatment guideline involved the elimination of post-reduction radiographs (which the guideline recommends for all patients). The treatment guideline eliminated 56 (88.9%, 95% CI, 78.4%–95.4%) pre-reduction radiographs, as compared to the standard practice of obtaining pre-reduction films for all cases of suspected shoulder dislocation (p < 0.0001)

Experienced emergency physicians are frequently certain of the diagnosis of anterior shoulder dislocation on clinical grounds alone and can comfortably and safely use this guideline for the selective elimination of pre-reduction radiographs. Compliance with the guideline substantially decreases pre-reduction radiographs. Validation of the guideline in other settings is warranted.