370 T!w Journal of Emergency Medkine

after a lapse of a five year period (x2==0.81, df.=l, pcO.367). The correlations between the two factors across the three phases, are between 0.52 and 0.92, indicating strongly the existence of a “general facto? of clinical competency. These results which are derived from i&per&m (different samples- different time) and dependent (same sample-different time) samples of emagency physicians, heavily favour the focus of assessing clinical competency in emergency medicine to variables which are related to the two (equally @ottant) basic factors. These results also reflect the stsbihty and consistency of the board examinations in assessing clinical competency during thispeziod

R 2 - PEDIATRICS

10 RADIAL HEAD SUBLUXATION Snyder, H, Department of Emergency Medicine, Albany Medical Center, Albany, New Yark. USA

Radial head subluxation (RHS) produces no radiographic abnormalities according to the literature. However, recent anecdotal case reports have identified displacement of the radiocapitellar line (RCL) in pediatric patients with RHS. To verify this finding, we retrospectively reviewed all patients less than 5 years of age who received elbow and forearm radiographs in our emergency depsrtment. Prom January 1988 through April 1989, we identified 20 cases of RHS. Five (25%) of the 20 radiographs were read by the attending radiologist as abnormal due to RCL displacement indicating subluxation of the radiocapitellar articulatior~ All 5 of these radiographs had RCL displacement greater than 3mm. The remaining normal radiographshadRCLdisplacementlessthanorequalto3mm. The presence of RCL displacement without disruption of the radiocspitellar articulation amfirms the diagnosis of RHS, but doesnotappeartochangeeeabmentaroutcomeinthissubsetof patients. Radiographs may not be mandatory when the diagnosis of RHS is certain Radiographs are necessary if tbe history (i.e. fall) or physical examination is atypical or if reduction is unsuccessful to rule out more serious injuries such as radial head dislocation or fracture.

11 USEFULNESS OF COMPARISON X-RAYS OF THE ELBOW IN PEDIATRIC UPPER LIMB INJURY Chacon, D, Kissoon, N, Brown, T, Galpin, R, University of Western Ontario. London Gntario, Canada

The elbow is a common site of injury in children. Evaluation of elbow radiographs is difficult for the inexperienced physician because ossification centers appear at various times during skeletal maturation. The need for comparison x-rays of the elbow to assist in diagnosis in pediatric injury has not been adequately assessed. Therefore, we conducted a feasibility study to determine whether comparison x-rays added significantly to the diagnosis of elbow injury in children. From May to November, 1986. elbow radiographs of 25 children under 16 years of age with acute upper extremity injury who had had comparison x-rays of the elbows were selected consecutively from the radiology department files. Two groups of physicians, trainees (T). and

staff emergency/radiologist (EP/R) were randomly asked to review the x-rays and arrive at a diagnosis. X-rays of the affected side (AS) and unaffected side (US) were randomized accord+ to generated random munbers. The results showed that the mean (M) percentage (%) of correct diagnoses @x) for T given one x-ray, AS, (0.96%) or two x-rays, AS+US, (0.98%) did not differ significantly from the hi% of correct Dx for EP/R given one x-ray, AS, (0.88%) or two x-rays AS+US, (0.86%). We conclude that in our setting, obtaining comparison x-rays of the elbows does not add significantly to srriving at a diagnosis.

UNDERSTANDING OF THE NEED FOR A PAINFUL PROCEDURE MAY MODIFY A CHILD’S RESPONSE TO PAIN THE EMERGENCY DEPARTMENT Kimwn, N, McGrath, PA, Glebe, D. Paediatric Pain Programme and Paediatric Emergency Department, Children’s Hospital of westernOntsri0, London Ontario, Canada

We studied 41 children (mean age 10.3 years. range 5 to 16 years) during suturing of lacerations to determine whether children understood the need for a painful procedure and whether this understanding altered pain perception. Observations included pain intensity rating using the visual Analogue Scale (VAS). After the procedure children were administered a questionnaire to determine whether they understood the need for the pnxedum and their previous painful experiences.

Forty three % (18/41) of the patients fully understood the need for anaesthetic infiltration while 34% (14/41) understood the need for sutures. All children (100%) had injections on a previous occasion while only 54% had sutures. Chikhen in the older age group (11 to 16 years) were more likely to understand thereasonforinjections(X2(l.n=41)=11.04,pc0.0001)thanin the 5 to 10 year age group, but not suturing. Mean VAS ratings were significantly lower in children who understood the need for infiltrations (n=18) vs those who did not (n=23) (t(39)=2.91,pcO.O06). VAS ratings did not differ significantly between those with a full knowledge of the reasons for suturing (n=14) and those who did not (n=27) (p>o.O5).

Our study suggests that: 1) A significant number of children do not fully understand the need for infiltration and suturing. 2) Full knowledge of the need for infiltration can result in lower pain ratings. Gur study implies that time spent by medical personnel explaining the need for infiltration and suturing to the child may be useful in modifying the painful SthUlUS.

13

THE USE OF HISTOACRYL TISSUE ADHESIVE FOR THE CLOSURE OF FACIAL LACERATIONS IN CHILDREN Wztson, DP, Guy’s Hospital, London, England

Suturing facial lacerations in children is traumatic to all concerned. This study was undertaken to assess Histoacryl (n- butyl cyanoacrylate) tissue adhesive in the closure of fifty traumatic facial lacerations in children. A new technique of applying the glue using capillary tubing was introduced and assessed. The complications and benefits of this technique are diSCUSSed