Comparison of clinical judgment and diagnostic ultrasonography in the diagnosis of acute appendicitis: experience with a score-aided diagnosis.

OBJECTIVE: To evaluate the diagnostic accuracy of clinical judgment and diagnostic ultrasonography (US) used routinely and to create a scoring system to aid diagnosis. DESIGN: Prospective, double-blind study. SETTING: University hospital, Denmark. SUBJECTS: 222 Consecutive patients suspected of having acute appendicitis admitted between 0800 and midnight from June 1990 to June 1992. INTERVENTIONS: 148 Patients (67%) underwent appendicectomy and the remaining 74 patients were observed. 193 Patients (87%) had a diagnostic US examination. 21 Predictive variables were collected prospectively to create a scoring system. MAIN OUTCOME MEASURES: Results of surgical pathological findings, clinical outcome (observed group), diagnostic US, and values of diagnostic score. RESULTS: The decision to operate was made by a junior surgeon solely on the clinical examination, which yielded a diagnostic accuracy of 76%, specificity of 58%, and negative appendicectomy rate of 36%. 193 Patients underwent diagnostic US conducted by the radiologist on call of whom 123 were operated on, 78 for histologically proven appendicitis. US had a diagnostic accuracy of 72%, sensitivity of 49%, and specificity of 88%. Of the 21 predictive factors for acute appendicitis 11 were significant (p < 0.05): total white cell count (WCC) (>10 x 10[9]/1), migration of pain to the right lower quadrant, gradual onset of pain, increasing intensity of pain, pain aggravated by movement, pain aggravated by coughing, anorexia, vomiting, indirect tenderness (Rovsing's sign), muscle spasm, and sex. These 11 predictors were assigned an appropriate weight, based on the likelihood ratio, and used to create a scoring system. The score performed poorly if it was used to separate patients for observation and those for appendicectomy. However, if the score was used with two cut-off points resulting in three test zones (low, intermediate, and high risk of having acute appendicitis), some diagnostic benefit was seen for those patients within the zones of high and low probability. CONCLUSION: The clinical judgment of a junior surgeon was disappointing, and diagnostic aids are desirable to reduce the negative appendicectomy rate. Diagnostic US performed poorly as a routine procedure. Application of an up to date scoring system might be of some help to patients with a high or low probability of acute appendicitis, but any conclusion about its clinical application cannot be drawn from this study.

Lack of correlation between ulnar variance and carpal bone angles on lateral radiographs in normal wrists.

It has been proposed that negative ulnar variance is a predisposing factor to development of posttraumatic carpal ligamentous instability. However, this implies that no correlation exists between ulnar variance and carpal bone angles in the normal wrist. Carpal bone angles on lateral wrist radiographs and ulnar variance were measured in a series of 75 normal wrists. The mean ulnar variance was -0.03 mm (SD 1.56, range -5 to 5). The correlation coefficients were 0.06, -0.11, and -0.05 between the ulnar variance, and radiolunate, radioscaphoid, and scapholunate angles, respectively. A correlation between the carpal angles on lateral wrist radiographs, and ulnar variance in normal wrists could not be demonstrated, suggesting that the presence of negative ulnar variance may serve as an impartial clue to the presence of ligamentous instability.

Observer variability in measurements of carpal bone angles on lateral wrist radiographs.

Determinations of carpal bone angles are used in the clinical evaluation of carpal malalignment. Eleven frequently referred radiological measures in lateral projection of the wrists in 23 wrists were assessed using different definitions of axes. Interobserver- and intraobserver variations were calculated. The standard deviation of the interobserver variation ranged from 2.60 degrees to 18.15 degrees, and the intraobserver variation from 1.89 degrees to 4.66 degrees depending on the angles measured. The use of three angles for the least observer variability in assessment of carpal alignment is recommended. These angles were defined from the following carpal bone axes: radius, the line through the center of the medullary canal at 2 cm and 5 cm proximal to the radiocarpal joint; lunate, the line perpendicular to the tangent of the two distal poles; scaphoid, the tangent of the palmar proximal and distal margins, and capitate, the tangent of the dorsal margin of the diaphysis of the third metacarpal bone (substitute axis).

Monteggia lesions in children and adults: an analysis of etiology and long-term results of treatment.

The mechanism of trauma and late results of treatment were analyzed in 17 pediatric and 16 adult Monteggia lesions. Pediatric Monteggia lesions were almost entirely found to be the result of low energy trauma leading to a closed, noncomminuted fracture in an otherwise noninjured child. In the adult cases, however, these lesions were most often found to be the result of high energy trauma leading to open and comminuted fractures. Furthermore, 62% of the adults had other, and often more serious, injuries. Results at follow up (average 7 years) were excellent in the pediatric cases, whereas all adults had sequelae, especially regarding range of motion. The results of this study clearly suggest that a Monteggia lesion represents a more severe injury in the adult.

Hip fractures in children. A long-term follow up of 17 cases.

Late results (average 18 years posttrauma) after hip fractures in 17 children are reported. The average age at the time of fractures was 8.5 years (range 2 to 15 years). The treatment was conservative for undisplaced or slightly displaced transcervical and cervicotrochanteric fractures (Delbet's Type II and III) as well as for intertrochanteric fractures (Delbet's Type IV). The overall complication rate was 25%. Avascular necrosis of the femoral head was seen in two hips, premature epiphyseal closure with leg shortening in two cases, and a coxa vara in one hip. These complications only had resulted in few symptoms at follow up.