Introduction and Aims Back pain patients usually demand more time in clinic. A significant proportion of this time is spent in performing clinical examination. It has been recognised that detailed history of symptoms is the backbone in reaching the diagnosis and deciding the management plan for patients with lower back pain and/or radiculopathy. The aim of the study was to look at 1) Contributions from History and Examination. 2) Does Clinical Examination add any further information not identified from history?. Method A prospective, blinded study was carried out to determine the usefulness of history and clinical examination, individually to reach the diagnosis and plan the management. 75 consecutive lower back pain and/or radiculopathy patients were included in the study. Two orthopaedic registrars saw all the patients. One took detailed history and the other registrar performed clinical examination. Both registrars based on their information arrived at a provisional diagnosis. A consultant also took history and examined these patients. MRI scan was done as per clinical indication. Results The data was analysed using standard statistics software. In all patients history suggested the possible diagnosis. Clinical examination did not add any further information to alter the course of management, which was planned for the patient. Clinical examination did not show any further information that was not identified in the MRI scan. Conclusion Clinical examination does not add to the body of information available from history. Clinical examination does not add any further information not available on the scan. Clinical examination should be performed for patients considered for surgery to document the findings; here both subjective and objective assessment should be performed. Examination is not a useful screening tool

Introduction. As modern day lifestyle is becoming more active so is the incidence of meniscal injuries on rise. An injury to the meniscus is a common orthopedic problem with the incidence of meniscal injury resulting in meniscectomy of 61 per 100,000 populations per year. The common practice in diagnosis of the meniscal injury involves clinical examination followed by radiological or arthroscopic confirmation. The clinical tests commonly performed are joint line tenderness (JLT), McMurray's Test (Non-weight bearing test) and Childress Test (Weight Bearing Test). Aim. In our study, we performed the comparative analysis of the validity parameters for components of clinical examination in form of Joint line tenderness, McMurray's test and Childress Test. Methodology. A retrospective analysis was performed on the database established using Orchard Sports Injury Classification System-8. Codes KC2 and KC3 (Meniscal injuries) were identified for single examiner for duration from 2004–2007. Out of 88 patients considered for the study, 62 patients were stratified in whom only clinical examination was performed followed by arthroscopic evaluation. The validity parameters considered were accuracy, specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV). Results. Joint line tenderness had accuracy of 85.47%, sensitivity of 89.09%, and specificity of 57.14%, PPV of 94.23% and NPV of 40%. McMurray's test yielded a accuracy of 88.7%, sensitivity of 89.65%, specificity of 75%, PPV of 98.11%, NPV of 33.33% while Childress test accurately predicted meniscal injury 87.09% and was sensitive for 94.73% with specificity of 40%, PPV of 94.73% and NPV of 40%. Conclusion. We can summarise that though the JLT, McMurray's Test and Childress Test provide a variable yet effective diagnostic value, all through can provide a composite diagnostic yield improving the outcome of clinical examination in meniscal injuries

Introduction. Meniscal injuries are very common cause of knee pain and resultant attendance to the orthopaedics or sports medicine clinics. The current protocol stands at clinical examination at first contact and establishing a diagnosis with clinical indicators like joint line tenderness, McMurray's, Apley's and weight-bearing test for meniscal pathology followed by MRI scan to confirm the diagnosis. Either surgical or conservative management follows this. We aim to assess clinical examination alone provide sufficient evidence for further management of meniscal injury and does a role of MRI scan exist to corroborate the findings. Methodology. We retrospectively studied 88 patients attending the sports medicine clinic for the duration 2004–2007 examined by senior clinical assessor. We investigated the co-relation of the clinical and MRI findings to validate if there exists an actual clinical justification to use MRI scan in every patient. We divided the data in further subsets of 57 patients in whom both clinical examination and MRI scan were performed and were validated by arthroscopy. The data obtained was analysed for parameters of accuracy, sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV]. Results. The comparison of clinical examination against MRI scans alone in 88 patients provided a accuracy of 81.81%, sensitivity of 95.77% and specificity of 23.52%. The assessment revealed that clinical examination yielded accuracy of 89.47%, sensitivity of 96%, specificity of 42 %, PPV of 92%, NPV of 60% while MRI scan was 87.70% accurate, 86% sensitive, with specificity of 100%, PPV of 100%, NPV of 57.14%. Conclusion. From the results yielded by the study we can conclude that in experienced hands the clinical examination is as robust as MRI scan for meniscal injury of knee and can negate the need for MRI scan to be performed in every painful knee with suspicious meniscal injury

The purpose of the study was to assess the accuracy of clinical examination to diagnose meniscal injury. Internal Derangement of Knee is one of the most common conditions encountered in routine orthopaedic practice. The ultimate outcome depends upon timely management based on correct diagnosis. There are various tools available to diagnose this condition, mainly clinical examination, MRI & Arthroscopy. The individual method needs to be evaluated on the basis of merits and demerits depending upon the cost, time spent waiting for results and the degree of accuracy it provides. The study was carried out retrospectively by looking at case notes of 98 patients, who had arthroscopy of the knees with or without MRI. An attempt was made to establish the correlation between the arthroscopic diagnosis and the clinical signs looked for to diagnose meniscal injury. The result of the study showed that although the accuracy to diagnose the internal derangement prior to arthroscopy was fairly high, poor documentation of clinical examination findings, defeated the purpose of the assessment of accuracy. From patient’s management point of view, it appears that Arthroscopy & MRI have become indispensable tools in the evaluation of the injured knee. They can provide the physician and patient pre treatment prognosis. However they must be utilized as a complimentary to (not instead of) clinical evaluation and judgment. They become less cost-effective if used in a less responsible manner without the appropriate first-line investigations i.e. accurate clinical examination

Introduction and Aims: Back pain patients usually demand more time in clinic. A significant proportion of this time is spent in performing clinical examination. It has been recognised that a detailed history of symptoms is the backbone in reaching the diagnosis and deciding the management plan for patients with lower back pain and/or radiculopathy. Method: A prospective, blinded study was carried out to determine the usefulness of history and clinical examination, individually, to reach the diagnosis and plan the management. Sixty consecutive lower back pain and/or radiculopathy patients were included in the study. All the patients were seen by two orthopaedic registrars. Detailed history was taken by one and clinical examination was performed by the other registrar. A provisional diagnosis was made by both registrars based on their information. A consultant also took history and examined these patients. MRI scan was done as per clinical indication. Results: The gathered information was analysed using standard statistics software. The data indicates that clinical examination on its own was non-contributory in reaching diagnosis and plan the management. All information obtained by history alone correlated well with MRI results. The full results and cost implications will be discussed. Conclusion: Routine clinical examination of spine can be omitted without compromising the patient care, where clear history is available to reach diagnosis and plan the management. Clinical examination should be performed on those patients who need surgery to document the pre-operative neurology

The aim of this trial was to assess the clinical examination findings commonly used for the ACL deficient knee. For reliability testing and criterion validation 102 patients with ACL injuries were assessed by a single observer, 35 by a second observer and 47 again by the initial observer. For construct and criterion validation 30 patients were assessed pre-operatively and a mean of 1.7 years after ACL reconstruction. The Lysholm 11, Tegner and Cincinnati outcome measures were assessed along with instrumented knee laxity (Stryker test), the one hop test (OHT) and graded tests (including anterior draw, Lachman test, quality of end point, and pivot shift test). The outcome measures were found to be reliable except the Cincinnati system. All examination findings were of unsatisfactory reliability, with the exception of the OHT and the Stryker test. Construct validation revealed a significant improvement in all outcome measure scores and examination findings following ACL reconstruction. Criterion validation revealed that of the examination findings only the OHT had a satisfactory correlation with the symptom of giving way and the Lysholm/Tegner measures. Comparison of the difference between the desired and actual Tegner activity levels with the examination findings revealed an improvement in all levels of correlation. With the exception of the OHT, the clinical examination findings used for the ACL deficient knee are unreliable and correlate poorly with the functional outcome of the patient. They may, however, have some benefit in assessment of deficiency of the anatomical structures and the findings should be presented individually, rather than forming part of the functional assessment of the patient

Background. Thoracolumbar fractures are the most common spinal injuries resulting from blunt trauma. Missed spinal injuries can have serious consequences. Objective. Our objectives were to determine the utility of trauma series chest and abdomen computed tomographs for detecting clinically unrecognised vertebral fractures and to analyse those missed on clinical examination. The aim was to identify an ‘at-risk’ patient group with negative clinical examination warranting evaluation with CT screening. Material and Methods. We evaluated all computed tomography of the chest and/or abdominal that was undertaken for blunt trauma at our trauma centre from April 2009 to April 2010. Data was gathered from both CT scans and medical notes to capture demographics, mechanism of injury, fracture site and configuration. Key points were the clinical suspicion of vertebral fractures prior to CT request and identifying ‘at-risk’ patient group with factors contributing to difficulty in clinical interpretation. Results. There were a total of 303 patients in the year who underwent CT scan for blunt trauma. 51(16.8%) had a thoracolumbar vertebral fracture. There were 8 women and 43 men a mean age of 45.2 years. There were 29 (56.8%) stable and 22 (43.2%) unstable fractures. Out of the 51 total fracture patients, only 17(33.3%) had been clinically anticipated with a positive clinical examination. In the 22 unstable fractures, only 11 (50%) were expected and had clinically recorded correlating positive examination findings. Conclusion. A combination of both clinical examination and CT screening based on mechanism will likely be required to ensure adequate sensitivity with an acceptable specificity for the diagnosis of clinically significant injuries of the TL spine

Clinical decision-making could be difficult when Magnetic resonance imaging (MRI) is used for the diagnosis of knee injuries. We retrospectively studied 565 knee arthroscopies done between 2002 and 2005, 110 of which had suspected ligamentous injuries, evaluated clinically, with MRI and subsequently by arthroscopy. The aim of the study was to know the extent of correlation of clinical, MRI features with arthroscopy and whether MRI could be justifiably used to deny an arthroscopy. All patients with a strongly suggestive history were examined in the clinic by experienced orthopaedic surgeons and MRI was requested. Clinical examination was repeated under anaesthesia by the operating surgeon who not necessarily had examined the patient initially. The clinical and arthroscopy findings were recorded systematically. 3 Radiology consultants of varying musculoskeletal experience reported the MRI films. The clinical and MRI findings were compared with arthroscopy for the extent of correlation. We observed that overall Sensitivity of MRI for meniscal injuries was 73%, being more for medial than lateral and 86% for cruciate ligament injuries. Clinical examination had a sensitivity of 33% and a specificity of 93% for meniscal injuries, sensitivity of 86% and specificity of 100% for cruciate injuries. MRI was not able to demonstrate synovial plicae in 13 knees and chondral defects in 3 knees. 96 Knees, which were normal clinically, were found to have meniscal tears on MRI in 65 and subsequently confirmed by arthroscopy in 39. We conclude that an accurately performed clinical examination with positive signs alone, will be justified for arthroscopy and a negative MRI will not be a sufficient evidence to deny an arthroscopy. Also the reporting will largely depend on the quality of information provided by the clinician, technical factors and the musculoskeletal experience of the person reporting the films

With the increasing availability of magnetic resonance imaging, there is potentially less emphasis being placed on making a definitive clinical diagnosis. Changes in the undergraduate curriculum have also reduced the emphasis on orthopaedic clinical evaluation. This aim of this study was to evaluate the predictability of clinical examination alone in comparison with arthroscopic findings in 50 consecutive patients presenting for arthroscopy to our service. Four trainees examined each patient; each examiner was blinded to the clinical diagnosis made by their colleagues. All patients were examined in the ward and subsequently underwent examination under anaesthesia and arthroscopy. Of the tests for meniscal injuries joint line tenderness was the most sensitive (77%) and specific (68%). Apley’s and McMurray’s test while specific (92%, 98%) lacked sensitivity (9%, 30%). Overall the tests for anterior cruciate ligament (ACL) disruption were more reliable than the tests for meniscal injuries. The anterior drawer and Lachmann tests had high specificity (90%, 75%) and sensitivity. The pivot shift test also had very high specificity (75%) and sensitivity (98%) for detecting ACL injuries. These data demonstrate that joint line tenderness is the most reliable sign of menis-cal injury. In the absence of joint line tenderness Apley & McMurray’s tests have little role in routine clinical examination. Clinical tests and signs of ACL deficiency are consistently reliable in diagnosing ACL rupture

Introduction: Diagnosis of rotator cuff tears by clinical examination and MRI is not always accurate. If the extent of the tear could be predicted pre-operatively, both the patient and the surgeon would be better equipped for the subsequent operation and rehabilitation. Aim: To assess the accuracy of clinical examination and MRI in detecting the presence of rotator cuff tears. Method and Results: Retrospective analysis of 86 patients with symptoms and signs of rotator cuff disease. All underwent clinical examination of the shoulder followed by an MRI scan. The diagnosis was confirmed intra-operatively. Sensitivity of clinical examination for all tears was 69%, with a specificity of 64% and a positive predictive value of 80%. Individual sensitivities were as follows: grade I 50%, II 76%, III 100%. MRI had a sensitivity of 82.8% for all tears, specificity of 57% and a positive predictive value of 80%. Individual sensitivities: I 69%, II 90%, III 100%. Conclusion: In some patients clinical examination remains uncertain, MRI is helpful but the diagnosis is not always reliable

The aim of this study is to assess the accuracy of clinical examination of the knee compared to MRI and Arthroscopy in diagnosing significant internal derangement. We performed a retrospective analysis on 245 patients who underwent an MRI of the knee over a two-year period. The MRI diagnoses were compared with both clinical and arthroscopic findings. There were 169 male and 76 female patients with an average age of 33 years. A history of significant trauma was seen in 98 (40%) patients. The commonest clinical diagnosis was isolated medial meniscal tear (25%). Anterior cruciate ligament (ACL) tear was diagnosed in 8% and lateral meniscal tear in 7% of cases. No definite clinical diagnosis could be reached in 32% of patients. MRI showed no significant abnormality in 103 (42%) patients. Medial meniscal tear was noted in 47 (19%), ACL tear in 20 (8%) and lateral meniscal tear in 10 (4%) of the MRI scans. 96 patients (39%) proceeded to arthroscopy after their MRI scans. The mean time from MRI scan to arthroscopy was 181 days. The MRI and arthroscopy findings were in complete agreement in 90 (94%) patients. Of the 6 patients whose MRI findings did not correlate with arthroscopy, 4 showed meniscal tears not seen at surgery and two diagnosed ACL ruptures subsequently shown to be normal at arthroscopy. Three of the 4 meniscal tears were of the inferior surface of the posterior horn of the medial meniscus and one of the inferior surface of the lateral meniscus. The films were reviewed independently by three experienced MR radiologists all of whom confidently diagnosed a tear in each case. Clinical examination alone is not satisfactory in the diagnosis of knee injuries. MRI is a highly sensitive tool for diagnosis. Injuries that are commonly missed at arthroscopy can be diagnosed easily with MRI

Physical examination is critical to formation of a differential diagnosis in patients with ulnar-sided wrist pain. Although the specificity and sensitivity of some of those tests have been reported in the literature, the prevalence of positive findings of those provocative maneuvers has not been reported. The aim of the study is to find the prevalence of positive findings of the most commonly performed tests for ulnar sided wrist pain in a population presenting to UE surgeon clinics, and to correlate those findings with wrist arthroscopy findings.

Patients with ulnar sided wrist pain were identified from a prospective database of patients presented with wrist pain from September 2014. Prevalence of positive findings for the following tests were gathered: ECU synergy test, ECU instability test (Ice cream and Fly Swatter), Lunotriquetral ballottement, Kleinman shear, triquetrum tenderness, triquetrum compression test, triquetral-hamate tenderness, pisotriquetral shuck test, ulnar fovea test, ulnocarpal impaction (UCI) maneuver, UCI maneuver with fovea pressure (ulnar carpal plus test), piano key sign. A subgroup was then created for those who underwent wrist arthroscopy, and analysis of the sensitivities, the specificities and the predictive values of these provocative tests was carried out with correlation to arthroscopic finding.

Prevalence of ECU instability tests was t 1.13% (ice cream scoop) and 1.5% (fly swatter). Lunotriquetral ballottement test's positive findings range from 4.91% (excessive laxity) to 14.34% (pain reproducing symptoms. The Kleinman shear test yielded pain in 13.58% of patients, and instability in only 2.26%. Triquetrum compression test reproduces pain in 32.83% of patients, and triquetral-hamate tenderness reproduced pain in 13.21%. Pisotriquetral grind test yields 15.85% positive findings for pain, and 10.57% for crepitus with radioulnar translation. The ulnar fovea test revealed pain in 69.05% of cases. The UCI maneuver yielded pain in 70.19%. The UCI maneuver plus ulnar fovea test reproduced pain in 80.38% of cases. Finally, the piano key sign yields positive finding in 2.64% of cases.

For patients who underwent surgery, sensitivities, specificities and predictive values were calculated based on arthroscopic findings. The lunotriquetral ballottement test has 59.6% sensitivity, 39.6% specificity, 20.3% positive predictive value and 85.4% negative predictive value. The sensitivity of Kleinman test was 62.4%, the specificity was 41.3%, the positive predictive value was 23.5%, and the negative predictive value was 83.2%. The sensitivity of fovea test was 94.3%, the specificity was 82.5%, the positive predictive value was 89.5% and the negative predictive value was 92.3%. The UCI maneuver plus ulnar fovea test has 96.5% sensitivity, 80.7% specificity 86.4% positive predictive value, and 95.3% negative predictive value.

Among the provocative tests, the prevalence of positive findings is low in the majority of those maneuvers. The exceptions are the fovea test, the UCI maneuver, and the UCI plus maneuver. With regard to the sensitivity and the specificity of those tests, the current study reproduces the numbers reported in the literature. Of those patients who underwent wrist arthroscopy, the tests are better at predicting at the absence of injury rather than at predicting its presence

Introduction. There are over 110 special tests described in the literature for clinical examination of the shoulder, but there is no general consensus as to which of these are the most appropriate to use. Individual opinion appears to dictate clinical practice. Rationalising which tests and clinical signs are the most useful would not only be helpful for trainees, but would also improve day to day practice and promote better communication and understanding between clinicians. Methodology. We sent a questionnaire survey to all shoulder surgeons in the UK (BESS members), asking which clinical tests each surgeon found most helpful in diagnosing specific shoulder pathologies; namely sub-acromial impingement, biceps tendonitis, rotator cuff tears and instability; both anterior and posterior. Results. For impingement; Hawkins-Kennedy and Neer's tests were used by the majority of respondents, with 50% also routinely performing Neer's injection test. For frozen shoulder; the shoulder quadrant test was the commonest used, followed by loss of passive range of motion and loss of external rotation. For biceps tendonitis; Speed's and Yergason's tests were by far the commonest used. For rotator cuff tears the commonest signs were; the Napoleon belly press, Hornblower's sign, Gerber's sign, Jobe's sign and Codman's drop arm sign. For instability; the apprehension test, the Gerber-Ganz drawer test, load and shift test and Jobe's relocation test were the commonest used, with the jerk test also popular for posterior instability. We are also currently assessing how individuals actually perform these tests, and whether they are as the original authors described them. Conclusion. Our results demonstrated some variation in which tests were being used, but with an increased preference for certain tests. Interestingly a large number of respondents commented that the history was of paramount importance and that clinical signs should only substantiate the clinician's diagnosis

Disorders of human joints manifest during dynamic movement, yet no objective tools are widely available for clinicians to assess or diagnose abnormal joint motion during functional activity. Machine learning tools have supported advances in many applications for image interpretation and understanding and have the potential to enable clinically and economically practical methods for objective assessment of human joint mechanics. We performed a study using convolutional neural networks to autonomously segment radiographic images of knee replacements and to determine the potential for autonomous measurement of knee kinematics. The autonomously segmented images provided superior kinematic measurements for both femur and tibia implant components. We believe this is an encouraging first step towards realization of a completely autonomous capability to accurately quantify dynamic joint motion using a clinically and economically practical methodology.

Objective: The aim of this study was to show the effect of a universal (all neonates) ultrasound screening in newborns on the incidence of operative treatment of hip dysplasia. Materials: A retrospective study was performed and all newborns of the county Tyrol (Austria) between 1978 and 1998 (8257 births / year ((range: 7766 – 8858)) were reviewed regarding hip dysplasia and following hip surgeries. Between 1978 and 1983 clinical examination alone was performed to detect hip dysplasia. Between 1983 and 1988 an ultrasound screening programme according to Graf was initiated in our county. Between 1988 and 1998 ultrasound screening was performed in all newborns. Hence two observation periods were determined: 1978–1983 and 1993–1998. The time period between 1983 and 1993 was excluded to minimize bias and learning curve regarding the initiation of the ultrasound screening programme. A retrospective comparative analysis of the two observation periods regarding surgical treatment and costs caused by hip dysplasia was performed. During the observation period indication for surgery did not change, however new treatment techniques were introduced. Patients with neuromuscular and Perthes diseases were excluded. According to age dependent surgical procedures three patient samples were determined: Group A: 0–1.5 years, Group B: 1.5–15 years and Group C: 15–35 years. Results: Comparison of the two observation periods showed no influence on the number of interventions for dysplastic hips in group C (pelvic osteotomies and VDROs). In group A, a decrease of hip reductions was seen from 25.6±3.2 to 7.0± 1.4 cases per year. In group B, there was a decrease of operative procedures for dysplastic hips from 18.0±3.2 to 3.4±1.3 interventions per year. Since the introduction of universal hip ultrasound screening the decrease of the total number of interventions for all groups was 78.6%. Comparison of costs of the two observation periods showed an increase of all costs caused by DDH and CDH of 57.000 euro/ year for the time period between 1993 and 1998 which was mainly caused by the ultrasound screening programme. There was a significant reduction of costs regarding operative and non operative treatment for dysplastic hips from 410.000 euro (1978–1983) to 117.00 euro (1993–1998). Conclusion: Initially there were higher costs caused by the screening method, but on the other hand total number and costs for operative and nonoperative treatment of dysplastic hips were significantly reduced by the universal ultrasound screening programme. In our mind patient’s and family distress and pain related to interventions performed for CDH and DDH justify the slight increase of costs caused by the universal screening programme. We therefore recommend universal hip ultrasound screening for neonates

Introduction: To guide one’s surgical options if conservative treatment in metatarsalgia fails, a good understanding of the anatomy and the biomechanics of a normal forefoot is primordial. The recognition of a so-called ideal morphotype may serve as a guide, through technical or other means (clinical examination, X-rays, baropodometry,..), to obtain a calculated and subtle reconstruction of all the symptomatic elements. Material and Methods: Between 2000 and 2005, 68 patients were operated by the same surgeon and were all, but five, reviewed retrospectively by an independent examiner. The study of the 184 osteotomies performed (of which 177 Weil osteotomies), made use of clinical, and radiological computerised analysis. Results: We have not been able to find a significant correlation between a harmonious curve of Maestro and postoperative recurrence or transfert metatarsalgia. Discussion: The cause of transfert metatarsalgia is often hard to find. Known, and so evitable, are important shortening and a fault in the preoperative adjustment. Despite a precise preoperative planning and a perfectly performed surgical technique, the surgeon sometimes encounters the development of plantar callosities beneath metatarsal heads adjacent to the operated ones. Lots of variables are still unknown or not recognised: mobility at the Lisfranc, gastrocnemius retraction. We have noted a significant relationship between the preoperative (in-)stability and the risk of developing transfert metatarsalgia (p-value = 0.03). A metatarso-phalangeal articulation, unstable in the preop setting, has 0.36 times less the risk of leading to this complication than if the operation was performed on a stable articulation preoperatively. A stable articulation would so be an indirect sign of a good tolerance by the adjacent rays. Conclusion: One can question if the reconstruction of an architectural harmonious forefoot using the ideal curve of Maestro at any price is necessary, since we were not able do demonstrate a guaranteed postoperative pain relief. A respect of the so-called ideal morphotype of the forefoot on the dorsoplantar upright X-rays seems insufficient in the assurance of a balanced distribution of plantar pressures postoperatively. Certainly, this morphotype most probably avoids an elevated rate of complications, but may not be considered as the only criteria to be achieved. The clinical examination stays the most essential element. Only the preoperatively symptomatic and unstable metatarsals should probably undergo this osteotomy

Objective evaluations of resident performance can be difficult to simulate. A novel competency based surgical OSCE was developed to evaluate surgical skill. The goal of this study was to test the construct validity comparing previously validated Ottawa scores (O-scores) and Orthopaedic in-training evaluation scores (OITE).

An OSCE designed to simulate typical general orthopaedic surgical cases was developed to evaluate resident surgical performance. Post-graduate year (PGY) 3–5 trainees have an encounter (interview and physical exam) with a standardized patient and perform a correlating surgery on a cadaver. Examiners evaluate all components of the treatment plan and provide an overall score on the OSCE and also provide an O-score on overall surgical performance. Convergent and divergent validity was assessed comparing OSCE scores to O-scores and OITE scores. SPSS was used for statistical analysis. ANOVA was used to compare PGY averages and Pearson correlation coefficients were calculated to compare OSCE versus O-score and OITE scores.

A total of 96 simulated surgical cases were evaluated over a 3 year period for 24 trainees. There was a significant difference in OSCE scores based on year of training. (PGY3 − 6.06/15, PGY4 − 8.16/15 and PGY5 − 11.14/15, p < 0 .001). OSCE and O-scores demonstrated a strong positive correlation of +0.89 while OSCE and OITE scores demonstrated a moderate positive correlation of 0.68.

OSCE scores demonstrated strong convergent and moderate divergent correlation. A positive trajectory based on level of training and stronger correlations with established, validated scores supports the construct validity of the novel surgical OSCE.

Scaphoid fractures are rare injuries in the pediatric population. A clinical and radiographic review over a six-year period at our institution revealed ninety-nine suspected scaphoid fractures. All of these patients presented with post-traumatic tenderness in the anatomic snuffbox and were treated with thumb spica cast immobilization. Only 9% of these patients demonstrated radiographic evidence of scaphoid fracture on initial presentation. At subsequent follow-up, six additional patients revealed radiographic evidence of scaphoid fracture. Positive predictive value of snuffbox tenderness for scaphoid fracture was 6% for patients with initially normal radiographs.

To review the clinical and radiographic results of suspected pediatric scaphoid fractures, as well as to determine the predictive value of anatomic snuffbox tenderness for occult fracture.

Pediatric scaphoid fractures are rare injuries that were found to be non-displaced and to involve the waist and distal scaphoid in most cases. Snuffbox tenderness had a positive predictive value of 6% in the identification of occult fracture.

In cases of suspected scaphoid fracture and normal radiographs, reliance on anatomic snuffbox tenderness alone will result in unnecessary immobilization in the majority of children.

Ninety-nine potential injuries were identified. Average age was 13.9 years. Although all patients in this group had tenderness in the snuffbox, only nine of the original x-rays revealed a true scaphoid fracture. The ninety “clinical scaphoid fractures” were immobilized for twenty-three days on average. Of these, only six demonstrated future radiographic evidence of fracture. No injuries required surgery for non-union.

All pediatric scaphoid fractures that were diagnosed clinically or radiographically at our institution between 1998 and 2003 were reviewed. Initial and follow-up radiographs were examined for evidence of fracture.

Given the sequelae of untreated scaphoid fractures in adults, tenderness in the snuffbox has been used to diagnose “clinical scaphoid fractures”. Although never validated in children, this test continues to be used in this population. As the natural history of scaphoid fracture in children is more favorable than in adults, reliance on snuffbox tenderness alone has resulted in the over-treatment of this injury.

Background:

Glomus tumours of the hand are rare benign vascular tumours. The literature shows a limited number of case series with few patients treated over several years.

Pelvic x-ray is a routine part of the primary survey of Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard in the diagnosis of pelvic fractures. This study aims to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis, in favour of later pelvic CT scan.

A retrospective analysis of polytraumatized patients in our emergency room was conducted between 2005 and 2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and clinically stable pelvis. We excluded patients requiring immediate intervention.

We reviewed the records of 452 patients. 91 fulfilled inclusion criteria (56% male, mean age 45 years). 43% were road traffic accidents and 47% falls. In 68/91 (75%) patients, both pelvic x-ray and CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None false positive pelvic x-ray was detected. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23).

In hemodynamically stable patients with clinically stable pelvis, x-ray sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination. The results support the safety and utility of our modified ATLS algorithm