Baseline Clinical Exam Screening Tests for Select Red Flags

Body region Diagnosis Sx/Sy Diagnostic Accuracy Cervical Myelopathy CPR:

- Age > 45 - Gait abnormality - + Babinski - +Inverted Supinator - +Hoffman’s

1/5: Sn .94, Sp .31 2/5: Sn .39, Sp .88 3/5: Sn .19, Sp .99 4/5: Sn .09, Sp 1.0 (Cook, 2010)

Fracture Refer to Canadian C-spine rules

Sn .9-1.0 (Michaleff, 2012)

Instability Hx of trauma; RA, Down Syndrome; signs of cord compression - + Sharp Pursor - + Alar Ligament - + Anterior Shear

No clustered statistics published

Sharp Pursor: Sn .69, Sp .96, +LR 17.3 (Forrester, 1999)

Cervical Arterial Dissection

- Age > 40 - Recent head/neck trauma - Recent infection - Migraines

No published statistics

Malignancy CPR: - Past hx of CA - Age >50 - Recent unexplained weight loss - Failed conservative tx

Sn 1.0 (if all four absent) (Deyo, 1988)

Upper Extremity Coronary Artery Disease (CAD)

CPR:- Females > 65, males > 55 - Known clinical vascular disease - Pain worse during exercise - Pain not reproducible by palpation - Patient believes pain is of cardiac origin

Sn .98 (if two criteria met) (Bosner, 2010)

Elbow Fracture - Elbow Extension Test Sn .97, Sp .49 -LR: .03 (adults), .11 (children)(Appelboam, 2008)

Lumbo-pelvic Fracture CPR: - Age > 50 - Female gender - Major trauma - Pain and tenderness - Distracting injury

- Pelvic palpation

Unvalidated CPR (Henschke, 2008)

Sn .98, Sp .94, +LR 16.3 (McCormick, 2003)

Malignancy CPR: - Past hx of CA - Age >50 - Recent unexplained weight loss - Failed conservative treatment

Sn 1.0 (if all four absent) (Deyo, 1988)

Cauda Equina Syndrome

- Urinary Retention - Bladder dysfunction - Major limb motor dysfunction - Saddle anesthesia

No clustered statistics published. Urinary Retention: Sn .90, Sp .95, +LR 18, -LR0.1 (Deyo, 1992)

Ankylosing Spondylitis

CPR:- Morning stiffness > 30 minutes - Improvement with exercise - Waking with back pain in the second half of the night - Alternating buttock pain

2/4: Sn .70, Sp .81, +LR 3.7 3/4: +LR 12.4 (Rudwaleit, 2006)

Lower Extremity

Knee Fracture CPR: - Age > 55 - Isolated patellar tenderness - Isolated fibular head tenderness - Inability to actively flex knee to 90 degrees - Inability to bear weight x 4 steps immediately following injury and in the ED

Sn .98, -LR .05 (Bachmann, 2004)

Malignancy CPR: - Past hx of CA - Age >50 - Recent unexplained weight loss - Failed conservative treatment

Sn 1.0 (if all four absent) (Deyo, 1988)

Deep Vein Thrombosis

Refer to Well’s Criteria Sn .82, Sp .22, +LR 1.06 (Tagelagi, 2007)

Ankle/Foot Fracture CPR: - Isolated medial/lateral malleolus, navicular, or base of the 5th metatarsal bony tenderness - Inability to bear weight x 4 steps immediately following injury and in the ED

Sn 1.0 (if all absent) (Stiell, 1993)

References 1. Cook, C. Clustered clinical findings for diagnosis of cervical spine myelopathy. 2. Michaleff, Z. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patientsfollowing blunt trauma: a systematic review. 3. Forrester, GA et al. Reliability and Validity of the Sharp-Purser Test in the Assessment of Atlanto-axial Instability in Patients with Rheumatoid Arthritis. Physiotherapy, Volume 85 , Issue 7 , 376. 4. Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. Journal of General Internal Medicine 1988;3:230–8. 5. Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ. 2010;182(2):1295-1300.6. Appelboam A, Reuben A D, Benger J R, Beech F, Dutson J, Haig S et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children BMJ 2008; 337:a2428. 7. Henschke N. A systematic review identifies five "red flags" to screen for vertebral fracture in patients with low back pain.8. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760–5. 9. McCormick, JP. Clinical effectiveness of the physical examination in diagnosis of posterior pelvic ring injuries. 10. Rudwaleit M, Metter A, Listing J, Sieper J, Braun J. Inflammatory back pain in ankylosing spondylitis. Arthritis Rheum.2006;54;569-578. 11. Bachmann, LM. The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review. 12. Tagelagi M, Elley CR. Accuracy of the Wells Rule in diagnosing deep vein thrombosis in primary health care. 13. Steill IG. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation.