History and radiographic findings associated with clinically suspected XXXX .

@entity1 @entity135 @entity130 @entity174
OBJECTIVES: To determine: 1) physician practices regarding the use of radiographs for @entity135 ( @entity135 ), 2) the prevalence of missed @entity174 in @entity1 with a clinical diagnosis of @entity135 , 3) the relative risk of a @entity174 with a nonclassic history for mechanism of injury for @entity135 , and 4) radiographic findings associated with @entity135 that are difficult to reduce. METHODS: This study began with a physician survey that addressed the integration of radiographs into the management of @entity135 . We subsequently conducted a prospective randomized trial with a consecutive sampling of @entity1 less than 6 years of age who presented to one of 2 urban pediatric emergency departments and 2 suburban pediatric urgent care centers with a clinical diagnosis of @entity135 . After informed consent was obtained, reduction was undertaken with a maximum of four attempts (two by hyperpronation and two by supination/flexion), 15 minutes apart. Failure to reduce the @entity135 resulted in the procurement of a radiograph of the elbow. At the conclusion of the study, all radiographs were evaluated by a radiologist blinded to the diagnosis. @entity1 receiving radiographs were contacted 2 weeks after discharge for verification of the diagnosis. RESULTS: Eighty-four percent of 224 physicians returned completed surveys. Fifty-six percent reported using radiographs for failed reduction attempts. In the second phase of the study, 136 @entity1 were enrolled prospectively: 127 were reduced successfully and 9 @entity1 failed attempts at reduction. Of the nine @entity1 receiving radiographs: four had @entity174 (prevalence of 2.9% with 95% confidence interval (CI) = 0.8-7.4), two had no radiographic findings and normal function on follow up, and three had isolated posterior fat pads on radiograph and normal function on follow-up. The relative risk of a @entity174 in @entity1 with a nonclassic history defined as any mechanism other than "pull" was 1.200 (95% CI = 0.441-3.264); the relative risk was 1.886 (95% CI = 0.680-5.231) when defining a nonclassic history as any mechanism other than "pull" or "fall." CONCLUSIONS: 1) Physicians tend to order radiographs for @entity130 they initially perceive to be @entity135 when attempts at reduction fail. 2) In our study, @entity174 in @entity1 who presented with the classic flexed elbow/pronated wrist position were rare. 3) The relative risk of a @entity174 in @entity1 with a nonclassic history for mechanism of injury was not significant. 4) An isolated finding of a posterior fat pad in a @entity1 with @entity135 that is difficult to reduce was not associated with a @entity174 in our small sample of @entity1 with radiographic findings.
