title: Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation.
abstract: BACKGROUND
  Most emergency physicians routinely obtain shoulder radiographs before and after shoulder dislocations. However, currently there is limited literature demonstrating how frequently new fractures are identified on post-reduction radiographs. The primary objective of this study was to determine the frequency of new, clinically significant fractures identified on post-reduction radiographs with a secondary outcome assessing total new fractures identified.
  
  
  METHODS
  We conducted a retrospective chart review using appropriate International Classification of Diseases, 9(th) Revision (ICD-9) codes to identify all potential shoulder dislocations that were reduced in a single, urban, academic emergency department (ED) over a five-year period. We excluded cases that required operative reduction, had associated proximal humeral head or shaft fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted separately by two study investigators with disagreements settled by consensus among three investigators. Images from indeterminate cases were reviewed by a radiology attending physician with musculoskeletal expertise. The primary outcome was the percentage of new, clinically significant fractures defined as those altering acute ED management. Secondary outcomes included percentage of new fractures of any type.
  
  
  RESULTS
  We identified 185 total patients meeting our study criteria. There were no new, clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI [3.3%-10.7%]) total new fractures identified, all of which were without clinical significance for acute ED management.
  
  
  CONCLUSIONS
  Post-reduction radiographs do not appear to identify any new, clinically significant fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED setting for shoulder dislocations.
authors.affiliation: Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois.
authors.forename: Michael
authors.initials: M
authors.lastname: Gottlieb
authors.affiliation: Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois.
authors.forename: Damali
authors.initials: D
authors.lastname: Nakitende
authors.affiliation: Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois.
authors.forename: Laurie
authors.initials: L
authors.lastname: Krass
authors.affiliation: Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois.
authors.forename: Anupam
authors.initials: A
authors.lastname: Basu
authors.affiliation: Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois.
authors.forename: Errick
authors.initials: E
authors.lastname: Christian
authors.affiliation: Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois.
authors.forename: John
authors.initials: J
authors.lastname: Bailitz
mesh_terms: D002983:Clinical Competence; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008349:Manipulation, Orthopedic / Q000379:methods*; D020380:Needs Assessment; D017410:Practice Guidelines as Topic; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012783:Shoulder Dislocation / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy; D012784:Shoulder Fractures / Q000000981:diagnostic imaging*; D019564:Unnecessary Procedures; D014965:X-Rays
references.citation: Am J Emerg Med. 1992 Mar;10(2):149-51
references.pmid: 1586410
references.citation: Ann Emerg Med. 1996 Oct;28(4):399-402
references.pmid: 8839524
references.citation: Cochrane Database Syst Rev. 2014;4:CD004962
references.pmid: 24782346
references.citation: J Emerg Med. 2007 Aug;33(2):169-73
references.pmid: 17692769
references.citation: Cochrane Database Syst Rev. 2011;(4):CD004919
references.pmid: 21491392
references.citation: Clin Chem. 2003 Jan;49(1):7-18
references.pmid: 12507954
references.citation: Radiology. 2013 Nov;269(2):323-37
references.pmid: 24155283
references.citation: J Emerg Med. 2006 Jul;31(1):23-8
references.pmid: 16798149
references.citation: Am J Emerg Med. 1999 Nov;17(7):653-8
references.pmid: 10597082
references.citation: Ann Emerg Med. 2000 Aug;36(2):108-13
references.pmid: 10918101
references.citation: Ann Emerg Med. 2013 Aug;62(2):170-5
references.pmid: 23489654