William C. Doukas

Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement

OBJECTIVE To investigate the reliability and diagnostic accuracy of individual tests and combination of tests for subacromial impingement syndrome (SAIS). DESIGN A prospective, blinded study design. SETTING Orthopedic surgeon shoulder clinic. PARTICIPANTS Patients with shoulder pain (n=55, mean age=40.6y). INTERVENTIONS Patients were evaluated with 5 physical examination tests for SAIS: Neer, Hawkins-Kennedy, painful arc, empty can (Jobe), and external rotation resistance tests. Surgical diagnosis was the reference standard. MAIN OUTCOME MEASURES Diagnostic accuracy calculated with a receiver operating characteristic (ROC) curve and sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR). A forward stepwise binary logistic regression analysis was used to determine the best test combination for SAIS. An ROC curve analysis was also used to determine the cut point of the number of tests discriminating between the presence and absence of SAIS. Kappa coefficients and percent agreement assessed interrater reliability. RESULTS The ROC analyses revealed a significant area under the curve (AUC) (AUC=.67-.72, P<.05) for all tests, except for the Hawkins-Kennedy. The tests with a +LR greater than or equal to 2.0 were the painful arc (+LR=2.25; 95% CI, 1.33-3.81), empty can (+LR=3.90; 95% CI, 1.5-10.12), and the external rotation resistance tests (+LR=4.39; 95% CI, 1.74-11.07). Tests with -LR less than or equal to 0.50 were the painful arc (-LR=.38; 95% CI, .16-.90), external rotation resistance (-LR=.50; 95% CI, .28-.89), and Neer tests (-LR=.35; 95% CI, .12-.97). The regression analysis had no specific test combinations for confirming or ruling out SAIS. The ROC analysis was significant (AUC=.79, P=.001), with a cut point of 3 positive tests out of 5 tests. Reliability was moderate to substantial agreement (kappa=.45-.67) for the painful arc, empty can, and external rotation resistance tests and fair strength of agreement (kappa=.39-.40) for the Neer and Hawkins-Kennedy tests. CONCLUSIONS The single tests of painful arc, external rotation resistance, and Neer are useful screening tests to rule out SAIS. The single tests of painful arc, external rotation resistance, and empty can are helpful to confirm SAIS. The reliability of all tests was acceptable for clinical use. Based on reliability and diagnostic accuracy, the single tests of the painful arc, external rotation resistance, and empty can have the best overall clinical utility. The cut point of 3 or more positive of 5 tests can confirm the diagnosis of SAIS, while less than 3 positive of 5 rules out SAIS.

Evaluation of orthopaedic injuries in Operation Enduring Freedom.

Summary: Orthopaedic injuries constitute a majority of the combat casualties in recent U.S. military conflicts. Orthopaedic injuries sustained in Operation Enduring Freedom from December 2001 to January 2003 that were treated in forward-deployed military medical facilities and evacuated to a U.S. army medical center were reviewed. The spectrum of injuries included open fractures, amputations, neurovascular, and soft-tissue injuries. Forty-four patients (85%) received treatment beyond local wound care prior to arrival at a military medical center. Debridement and irrigation was the most commonly performed procedure due to the contaminated nature of these combat injuries. There were no infections among patients with open fractures, and no patients with external fixators had pin tract infections. None of the open fracture patients underwent primary internal fixation or primary wound closure. The average time from injury to wound coverage of the open fracture wounds was 12 days. Two amputations were infected and were treated with revision and delayed wound closure. There were no primary amputations done at our institution due to infection or ischemia. All arterial injuries underwent urgent revascularization in a field hospital. None of the arterial repairs required revision after evacuation to a medical center. Operation Enduring Freedom has been an excellent example of how early and aggressive intervention in a forward-deployed area has a significant effect on rehabilitative and reconstructive efforts at a rear echelon tertiary care center.

Diagnosis of superior labral lesions: comparison of noncontrast MRI with indirect MR arthrography in unexercised shoulders

ObjectiveTo prospectively compare the accuracy of noncontrast magnetic resonance imaging (MRI) with indirect MR arthrography (I-MRa) of unexercised shoulders for diagnosis of superior glenoid labral lesions.Materials and methodsInstitutional Review Board approval and patient informed consent were obtained for this prospective study. Superior labral findings on shoulder MRI and unexercised I-MRa studies of 104 patients were correlated with findings at arthroscopic shoulder surgery. Two musculoskeletal radiologists independently reviewed the two sets of MR images while blinded to arthroscopic results. For each radiologist, the McNemar test was used to detect statistically significant differences between techniques.ResultsThe superior labrum was intact in 24 and abnormal in 80 subjects. For detection of superior labral lesions by each radiologist, I-MRa was more sensitive (84–91%) than MRI (66–85%), with statistically significant improvement in sensitivity for one reader (p = 0.003). However, I-MRa was less specific (58–71%) than MRI (75–83%). Overall, accuracy was slightly improved on I-MRa (78–86%) compared with MRI (70–83%), but this difference was not statistically significant for either reader.ConclusionCompared with noncontrast MRI, I-MRa was more sensitive for diagnosis of superior glenoid labral lesions. However, the diagnostic value of I-MRa in shoulders remaining at rest is potentially limited by decreased specificity of the technique.

Reliability and Diagnostic Accuracy of History and Physical Examination for Diagnosing Glenoid Labral Tears

Background Glenoid labral tears provide a diagnostic challenge. Hypothesis Combinations of items in the patient history and physical examination will provide stronger diagnostic accuracy to suggest the presence or absence of glenoid labral tear than will individual items. Study Design Cohort study (diagnosis); Level of evidence, 1. Methods History and examination findings in patients with shoulder pain (N = 55) were compared with arthroscopic findings to determine diagnostic accuracy and intertester reliability. Results The intertester reliability of the crank, anterior slide, and active compression tests was 0.20 to 0.24. A combined history of popping or catching and positive crank or anterior slide results yielded specificities of 0.91 and 1.00 and positive likelihood ratios of 3.0 and infinity, respectively. A positive anterior slide result combined with either a positive active compression or crank result yielded specificities of 0.91 and positive likelihood ratio of 2.75 and 3.75, respectively. Requiring only a single positive finding in the combination of popping or catching and the anterior slide or crank yielded sensitivities of 0.82 and 0.89 and negative likelihood ratios of 0.31 and 0.33, respectively. Conclusion The diagnostic accuracy of individual tests in previous studies is quite variable, which may be explained in part by the modest reliability of these tests. The combination of popping or catching with a positive crank or anterior slide result or a positive anterior slide result with a positive active compression or crank test result suggests the presence of a labral tear. The combined absence of popping or catching and a negative anterior slide or crank result suggests the absence of a labral tear.

Orthopedic Injuries during Operation Enduring Freedom

ABSTRACT Orthopedic injuries comprise a majority of combat injuries seen in recent U.S. military conflicts. Interventions in the forward deployed area have played an important role in improving mortality rates of soldiers as well as outcome at a medical center level. A retrospective review was conducted on orthopedic injuries from Operation Enduring Freedom evaluated at Walter Reed Army Medical Center (WRAMC). Patients were grouped into one of five injury categories (open fracture, amputation, arterial injuries, neurological injuries, and soft tissue injury) with evacuation time (days from time of injury to arrival at WRAMC) and procedures performed before arrival at WRAMC evaluated. The average evacuation time for all orthopedic casualties was 7.9 days. There was an average of 2.6 procedures performed per patient before arrival at WRAMC. There was no difference in evacuation time among the injury groups. Those with only soft tissue injuries underwent fewer procedures than the other injury groups; however...

Simultaneous bilateral rupture of the pectoralis major tendon: A case report

Rupture of the pectoralis major is being reported with increasing frequency1. Historically, injuries typically have resulted from accidental trauma, whereas recent injuries have occurred as a result of athletic competition or weight-lifting. During the last three decades, treatment trends have progressed toward more aggressive, early surgical repair for most injuries2-8. We report the case of a patient who sustained simultaneous bilateral rupture of the pectoralis major tendon. To our knowledge, this condition has not been previously reported in the English-language literature. Our patient was informed that data concerning the case would be submitted for publication. The patient agreed and, additionally, voluntarily supplied us with the initial post-injury photograph (Fig. 1). Fig. 1 Photograph of the patient two days following injury, demonstrating severe ecchymoses over the anterior aspect of both arms. Aforty-year-old man with no history of any serious medical conditions was performing dips on wide-grip parallel bars. While attempting to lower himself maximally from this wide-gripped position, he felt simultaneous painful and audible “pops” in both axillae and fell to the ground. He noticed the immediate onset of pain with subsequent swelling and ecchymosis in the axillae, and he had markedly diminished strength in adduction and internal rotation of both arms. The morning after the injury, the patient noticed the development of ecchymoses on the anterior surface of the arms (Fig. 1). As a result of military travel, the patients presentation for medical attention was delayed by several weeks. During this time, the ecchymoses and pain largely resolved; however, there was continued, substantial bilateral weakness of arm adduction and internal rotation. The patient reported no history of complicating systemic medical illness or the use of fluoroquinolone or anabolic steroids. On physical examination, the patient …

Diagnostic Accuracy of History and Physical Examination of Superior Labrum Anterior-Posterior Lesions

CONTEXT Type I superior labrum anterior-posterior (SLAP) lesions involve degenerative fraying and probably are not the cause of shoulder pain. Type II to IV SLAP lesions are tears of the labrum. OBJECTIVE To determine the diagnostic accuracy of patient history and the active compression, anterior slide, and crank tests for type I and type II to IV SLAP lesions. DESIGN Cohort study. SETTING Clinic. PATIENTS OR OTHER PARTICIPANTS Fifty-five patients (47 men, 8 women; age = 40.6 ± 15.1 years) presenting with shoulder pain. INTERVENTION(S) For each patient, an orthopaedic surgeon conducted a clinical examination of history of trauma; sudden onset of symptoms; history of popping, clicking, or catching; age; and active compression, crank, and anterior slide tests. The reference standard was the intraoperative diagnosis. The operating surgeon was blinded to the results of the clinical examination. MAIN OUTCOME MEASURE(S) Diagnostic utility was calculated using the receiver operating characteristic curve and area under the curve (AUC), sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR). Forward stepwise binary regression was used to determine a combination of tests for diagnosis. RESULTS No history item or physical examination test had diagnostic accuracy for type I SLAP lesions (n = 13). The anterior slide test had utility (AUC = 0.70, +LR = 2.25, -LR = 0.44) to confirm and exclude type II to IV SLAP lesions (n = 10). The combination of a history of popping, clicking, or catching and the anterior slide test demonstrated diagnostic utility for confirming type II to IV SLAP lesions (+LR = 6.00). CONCLUSIONS The anterior slide test had limited diagnostic utility for confirming and excluding type II to IV SLAP lesions; diagnostic values indicated only small shifts in probability. However, the combination of the anterior slide test with a history of popping, clicking, or catching had moderate diagnostic utility for confirming type II to IV SLAP lesions. No single item or combination of history items and physical examination tests had diagnostic utility for type I SLAP lesions.

Process of care for battle casualties at walter reed army medical center. Part IV. Occupational therapy service

Physical therapists, physical therapy assistants, and physical therapy technicians provide care to soldiers, sailors, Marines, and airmen returning from Operation Enduring Freedom and Operation Iraqi Freedom. We describe the inpatient and outpatient services provided, the problems and solutions encountered, and the lessons learned at the beginning of the war.

Process of Care for Battle Casualties at Walter Reed Army Medical Center: Part I. Orthopedic Surgery Service

Walter Reed Army Medical Center has been a primary hub in the United States for receiving Army battle casualties from Operation Enduring Freedom and Operation Iraqi Freedom. We detail the process of care that was developed to effect the timely effective management of these casualties.

Descriptive analysis of patients undergoing shoulder surgery at a tertiary care military medical center.

Shoulder pain is a common musculoskeletal complaint. Patients with shoulder pain who are seeking care in a military tertiary setting in the United States have not been previously described. This study describes the clinical features of 55 patients (47 men, 8 women) undergoing shoulder surgery at a tertiary care military medical center. Patients presenting to a military medical center are different than other previously described samples in the literature. Specifically, the patients in this study had a known mechanism of injury (n = 42; 76%), multiple structures involved (n = 46; 84%) and a high prevalence of glenoid labral involvement (n = 44; 80%). Further research is needed to determine if these patient characteristics identified in this study warrant different management strategies and resource utilization in both the tertiary care center, and in the primary care center where these patients are typically seen before referral to a tertiary care center.