title: Diagnostic accuracy of history, physical examination, and bedside ultrasound for diagnosis of extremity fractures in the emergency department: a systematic review.
abstract: OBJECTIVE
  Understanding history, physical examination, and ultrasonography (US) to diagnose extremity fractures compared with radiography has potential benefits of decreasing radiation exposure, costs, and pain and improving emergency department (ED) resource management and triage time.
  
  
  METHODS
  The authors performed two electronic searches using PubMed and EMBASE databases for studies published between 1965 to 2012 using a strategy based on the inclusion of any patient presenting with extremity injuries suspicious for fracture who had history and physical examination and a separate search for US performed by an emergency physician (EP) with subsequent radiography. The primary outcome was operating characteristics of ED history, physical examination, and US in diagnosing radiologically proven extremity fractures. The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2).
  
  
  RESULTS
  Nine studies met the inclusion criteria for history and physical examination, while eight studies met the inclusion criteria for US. There was significant heterogeneity in the studies that prevented data pooling. Data were organized into subgroups based on anatomic fracture locations, but heterogeneity within the subgroups also prevented data pooling. The prevalence of fracture varied among the studies from 22% to 70%. Upper extremity physical examination tests have positive likelihood ratios (LRs) ranging from 1.2 to infinity and negative LRs ranging from 0 to 0.8. US sensitivities varied between 85% and 100%, specificities varied between 73% and 100%, positive LRs varied between 3.2 and 56.1, and negative LRs varied between 0 and 0.2.
  
  
  CONCLUSIONS
  Compared with radiography, EP US is an accurate diagnostic test to rule in or rule out extremity fractures. The diagnostic accuracy for history and physical examination are inconclusive. Future research is needed to understand the accuracy of ED US when combined with history and physical examination for upper and lower extremity fractures.
authors.affiliation: Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA.
authors.forename: Nikita
authors.initials: N
authors.lastname: Joshi
authors.forename: Alena
authors.initials: A
authors.lastname: Lira
authors.forename: Ninfa
authors.initials: N
authors.lastname: Mehta
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Paladino
authors.forename: Richard
authors.initials: R
authors.lastname: Sinert
mesh_terms: D015331:Cohort Studies; D004636:Emergency Service, Hospital; D019317:Evidence-Based Medicine; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis* / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D035002:Lower Extremity / Q000293:injuries; D008297:Male; D008487:Medical History Taking / Q000379:methods*; D010808:Physical Examination / Q000379:methods*; D019095:Point-of-Care Systems; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D018608:Ultrasonography, Doppler / Q000379:methods*; D034941:Upper Extremity / Q000293:injuries