THE USE OF RADIOGRAPHS TO EVALUATE SHOULDER PAIN IN THE ED

This study was conducted to describe the utilization of plain radiogra phy in the initial evaluation of shoulder pain in the emergency depart ment (ED) and assess the feasibility of developing guidelines for the selective use of shoulder radiographs by determining whether clinical variables are able to discriminate between subjects having therapeutic ally informative versus uninformative X-rays. The study was a chart re view of all adult ED patients presenting to the Boston University Medi cal Center Hospital (Boston, MA) between January 1994 and January 1996 with a chief complaint that included shoulder pain. Subjects with X-r ays were classified into two groups, those with therapeutically inform ative X-rays tie, identified conditions requiring specific therapy) an d those with therapeutically uninformative X-rays tie, did not result in specific therapy). Recursive partitioning techniques were then used to identify clinical variables that best distinguished between therap eutically informative and uninformative radiographs. Three hundred twe lve patients were included in the analysis, of whom 185 (59%) had shou lder X-rays performed. Thirty-seven (20%) radiographs were therapeutic ally informative, including 13 glenohumeral dislocations, 3 acromiocla vicular joint separations, and 21 fractures. Deformity present on shou lder examination was the strongest discriminating variable and correct ly classified 21 of 23 subjects as having informative X-rays. Of the r emaining patients (n = 162), only those older than 43.5 years with a h istory of a precipitating fall (n = 40) had a high likelihood of havin g therapeutically informative X-rays. No patients without a deformity or precipitating fall (n = 90) had an informative X-ray. These data sh ow that X-rays for the initial evaluation of shoulder pain in the ED a re overutilized. This preliminary model suggests that clinical variabl es are able to distinguish between patients with informative versus un informative X-rays. Prospective studies are needed to derive valid dec ision rules for selective use of shoulder radiographs in the ED. (Am J Emerg Med 1998;16:560 563. Copyright (C) 1998 by W.B. Saunders Compan y).