title: Deriving the East Riding Elbow Rule (ER2): a maximally sensitive decision tool for elbow injury.
abstract: OBJECTIVE
  To derive a maximally sensitive decision rule for clinical practice to rule out the need for x-ray examination after elbow injury in adults and children.
  
  
  METHODS
  Emergency department patients with acute elbow injury were recruited. Practitioners used their usual judgement to assess whether x-ray examination was required. Radiographs were reported on by radiologists blind to clinical assessment. Patients not x-rayed were followed-up at 7 days by telephone interview, and those with ongoing pain were recalled for assessment. Recursive partitioning was used to derive a maximally sensitive decision tool. Inter-rater variability for significant discriminators was subsequently evaluated by a cohort of 20 emergency department clinicians.
  
  
  RESULTS
  492 patients were recruited (May 2006-November 2008): 50.4% were male; 26.8% were children; 444 (90.2%) had an x-ray; 167 (37.6%) showed abnormality. A follow-up telephone interview was conducted with 28; none were recalled. Thirteen could not be contacted, none of whom returned within 3 months. Sixteen patients with fractures were able to fully extend their elbow. The sensitivity of elbow extension alone was 84% (95% CI 77% to 88%), with specificity of 54% (95% CI 53% to 58%). A 100% sensitive (95% CI 97% to 100%) decision rule for adults (n=348) was derived based on (1) inability to fully extend the elbow, (2) tenderness over radial head, olecranon or medial epicondyle, and (3) presence of bruising (specificity 24% (95% CI 19% to 30%)). A similar rule for children could not be derived.
  
  
  CONCLUSIONS
  A simple and highly sensitive clinical decision rule for adult elbow fracture was derived in our cohort. A validation study in a second population is now required. At present, we are unable to recommend a rule-out strategy for elbow injuries in children.
authors: Emergency Department, Hull Royal Infirmary, Hull, UK.
authors: David
authors: D
authors: Arundel
authors: Emergency Department, Hull Royal Infirmary, Hull, UK.
authors: Paul
authors: P
authors: Williams
authors: Emergency Department, Hull Royal Infirmary, Hull, UK.
authors: Will
authors: W
authors: Townend
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003661:Decision Support Techniques; D003663:Decision Trees; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011859:Radiography; D011885:Radius Fractures / Q000000981:diagnostic imaging*; D016059:Range of Motion, Articular; D012680:Sensitivity and Specificity; D014458:Ulna Fractures / Q000000981:diagnostic imaging*; D055815:Young Adult; D000092464:Elbow Injuries
keywords: Trauma, extremity; clinical assessment; imaging, x-ray; musculo-skeletal, fractures and dislocations; x-ray