Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies.

BACKGROUND: Plain radiographs cannot identify all scaphoid fractures; thus ED patients with a clinical suspicion of scaphoid injury often undergo immobilisation despite normal imaging. This study determined (1) the prevalence of scaphoid fracture among patients with a clinical suspicion of scaphoid injury with normal radiographs and (2) whether clinical features can identify patients that do not require immobilisation and further imaging. METHODS: This systematic review of diagnostic test accuracy studies included all study designs that evaluated predictors of scaphoid fracture among patients with normal initial radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analyses included all studies. RESULTS: Eight studies reported data on 1685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 9.0%. Most studies were at overall low risk of bias but two were at unclear risk; all eight were at low risk for applicability concerns. The most accurate clinical predictors of occult scaphoid fracture were pain when the examiner moved the wrist from a pronated to a supinated position against resistance (sensitivity 100%, specificity 97.9%, LR+ 45.0, 95% CI 6.5 to 312.5), supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR+ 3.7, 95% CI 2.2 to 6.1), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR+ 2.3, 95% CI 1.8 to 3.0) and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR+ 2.0, 95% CI 1.2 to 3.2). Absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1%, specificity 48.4%, LR- 0.2, 95% CI 0.0 to 0.7). CONCLUSION: No single feature satisfactorily excludes an occult scaphoid fracture. Further work should explore whether a combination of clinical features, possibly in conjunction with injury characteristics (such as mechanism) and a normal initial radiograph might exclude fracture. Pain on supination against resistance would benefit from external validation. TRIAL REGISTRATION NUMBER: CRD42021290224.

Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies.

BACKGROUND: Prereduction radiographs are conventionally used to exclude fracture before attempts to reduce a dislocated shoulder in the ED. However, this step increases cost, exposes patients to ionising radiation and may delay closed reduction. Some studies have suggested that prereduction imaging may be omitted for a subgroup of patients with shoulder dislocations. OBJECTIVES: To determine whether clinical predictors can identify patients who may safely undergo closed reduction of a dislocated shoulder without prereduction radiographs. METHODS: A systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. The search was updated to 23 June 2022 and language limits were not applied. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data were pooled and meta-analysed by fitting univariate random effects and multilevel mixed effects logistic regression models. RESULTS: Eight studies reported data on 2087 shoulder dislocations and 343 concomitant fractures. The most important potential sources of bias were unclear blinding of those undertaking the clinical (6/8 studies) and radiographic (3/8 studies) assessment. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (positive likelihood ratio (LR+) 1.8, 95% CI 1.5 to 2.1; negative likelihood ratio (LR-) 0.4, 95% CI 0.2 to 0.6), female sex (LR+ 2.0, 95% CI 1.6 to 2.4; LR- 0.7, 95% CI 0.6 to 0.8), first-time dislocation (LR+ 1.7, 95% CI 1.4 to 2.0; LR- 0.2, 95% CI 0.1 to 0.5) and presence of humeral ecchymosis (LR+ 3.0-5.7, LR- 0.8-1.1). The most important mechanisms of injury were high-energy mechanism fall (LR+ 2.0-9.8, LR- 0.4-0.8), fall >1 flight of stairs (LR+ 3.8, 95% CI 0.6 to 13.1; LR- 1.0, 95% CI 0.9 to 1.0) and motor vehicle collision (LR+ 2.3, 95% CI 0.5 to 4.0; LR- 0.9, 95% CI 0.9 to 1.0). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6% to 99.2%) and a specificity of 33.3% (95% CI 23.1% to 45.3%), but the Fresno-Quebec rule identified all clinically important fractures across two studies: sensitivity of 100% (95% CI 89% to 100%) in the derivation dataset and 100% (95% CI 90% to 100%) in the validation study. The specificity of the Fresno-Quebec rule ranged from 34% (95% CI 28% to 41%) in the derivation dataset to 24% (95% CI 16% to 33%) in the validation study. CONCLUSION: Clinical prediction rules may have a role in supporting shared decision making after shoulder dislocation, particularly in the prehospital and remote environments when delay to imaging is anticipated.

The effects of different protocols of physical exercise and rest on long-term memory.

Whilst there are many studies comparing the different effects of exercise on long-term memory, these typically adopt varying intensities, durations, and behavioural measures. Furthermore, few studies provide direct comparisons between exercise and different types of rest. Therefore, by providing a standardised methodological design, this study will ascertain the most effective intensity and protocol of exercise for the modulation of long-term memory, whilst directly comparing it to different types rest. This was achieved using the same old/new recognition memory test and an 80-90 min retention interval. Three experiments were performed (total N = 59), each with a three-armed crossover design measuring the extent to which physical exercise and wakeful rest can influence long-term memory performance. In Experiment 1, the effects of continuous moderate intensity exercise (65-75% HRmax), passive rest (no cognitive engagement) and active rest (cognitively engaged) were explored. In Experiment 2, continuous moderate intensity exercise was compared to a type of high-intensity interval training (HIIT) and passive rest. Experiment 3 observed the effects of low- (55-65% HRmax), moderate- and high-intensity (75-85% HRmax) continuous exercise. Across the three experiments moderate intensity exercise had the greatest positive impact on memory performance. Although not significant, HIIT was more effective than passive-rest, and passive rest was more effective than active rest. Our findings suggest that it is not necessary to physically overexert oneself in order to achieve observable improvements to long-term memory. By also investigating wakeful rest, we reaffirmed the importance of the cognitive engagement during consolidation for the formation of long-term memories.