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European Journal of Trauma and Emergency Surgery

, Volume 41, Issue 6, pp 647–650 | Cite as

The accuracy of physical examination in identifying significant pathologies in penetrating thoracic trauma

  • V. Y. Kong
  • B. Sartorius
  • D. L. Clarke
Original Article

Abstract

Introduction

Accurate physical examination (PE) remains a key component in the assessment of penetrating thoracic trauma (PTT), despite the increasing availability of advanced radiological imaging. Evidence regarding the accuracy of PE in identifying significant pathology following PTT is limited.

Materials and methods

A retrospective review of 405 patients was undertaken over a twelve-month period to determine the accuracy of PE in identifying significant pathology (SP) subsequently confirmed on chest radiographs (CXRs) in patients who sustained stab injuries to the thorax.

Results

Ninety-seven per cent (372/405) of patients were males, and the mean age was 24 years. The weapons involved were knives in 98 % (398/405), screwdrivers in 1 % (3/405) and unknown in the remaining 1 %. Fifty-nine per cent (238/405) of all injuries were on the left side. There were 306 (76 %) SPs identified on CXR. Ninety-nine (24 %) CXRs were entirely normal. Based on PE alone, 223 (55 %) patients were thought to have SPs present, 182 (45 %) patients were thought to have no SPs. The overall sensitivity of PE in identifying SPs was 68 % (63–73, 95 % CI), with a specificity of 86 % (77–92, 95 % CI). The PPV of PE was 94 % (90–97, 95 % CI) and the NPV was 47 % (39–54, 95 % CI). The sensitivity of PE for identifying a pneumothorax was 59 % (51–66, 95 % CI), with a specificity of 96 % (89–99, 95 % CI) and the sensitivity of PE for identifying a haemothorax was 79 % (72–86, 95 % CI), with a specificity of 96 % (89–99, 95 % CI).

Conclusions

PE is inaccurate in identifying SPs in PTT. The increased reliance on advanced radiological imaging and the subsequent reduced emphasis on PE may have contributed to rapid deskilling amongst surgical residents. The importance of PE must be repeatedly re-emphasised.

Keywords

Penetrating thoracic trauma Physical examination Diagnostic accuracy 

Notes

Conflict of interest

Victor Kong, Benn Sartorius and Damian Clarke declare that they have no conflict of interest.

Compliance with ethics guidelines

Victor Kong, Benn Sartorius and Damian Clarke declare that all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients for being included in the study.

References

  1. 1.
    Hirshberg A, Thomson SR, Huizinga WK. Reliability of physical examination in penetrating chest injuries. Injury. 1988;19(6):407–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Advanced trauma life support for doctors. Student manual. 9th ed. Chicago: American College of Surgeons Committee on Trauma; 2012.Google Scholar
  3. 3.
    Lewis FR. Thoracic trauma. Surg Clin North Am. 1982;62:97–104.PubMedGoogle Scholar
  4. 4.
    Ho ML, Gutierrez FR. Chest radiography in thoracic polytrauma. AJR Am J Roentgenol. 2009;192(3):599–612. doi: 10.2214/AJR.07.3324.CrossRefPubMedGoogle Scholar
  5. 5.
    Sibbald M, Cavalcanti RB. The biasing effect of clinical history on physical examination diagnostic accuracy. Med Educ. 2011;45(8):827–34. doi: 10.1111/j.1365-2923.2011.03997.x.CrossRefPubMedGoogle Scholar
  6. 6.
    Kirkpatrick AW, Simons RK, Brown R, et al. The hand-held FAST: experience with hand-held trauma sonography in a level-I urban trauma center. Injury. 2002;33(4):303–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Thomson SR, Huizinga WK, Hirshberg A. Prospective study of the yield of physical examination compared with chest radiography in penetrating thoracic trauma. Thorax. 1990;45(8):616–9.PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Bhagwanjee S, Muckart DJ. Routine daily chest radiography is not indicated for ventilated patients in a surgical ICU. Intensive Care Med. 1996;22(12):1335–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Demetriades D, Rabinowitz B, Markides N. Indications for thoracotomy in stab injuries of the chest: a prospective study of 543 patients. Br J Surg. 1986;73:880–90.Google Scholar
  10. 10.
    Muckart DJ, Meumann C, Botha JB. The changing pattern of penetrating torso trauma in KwaZulu/Natal—a clinical and pathological review. S Afr Med J. 1995;85(11):1172–4.PubMedGoogle Scholar
  11. 11.
    Leigh-Smith S, Harris T. Tension pneumothorax—time for a re-think? Emerg Med J. 2005;22(1):8–16. doi: 10.1136/emj.2003.010421.PubMedCentralCrossRefPubMedGoogle Scholar
  12. 12.
    Diaz-Guzman E, Budev MM. Accuracy of the physical examination in evaluating pleural effusion. Cleve Clin J Med. 2008;75(4):297–303.CrossRefPubMedGoogle Scholar
  13. 13.
    Bokhari F, Brakenridge S, Nagy K, et al. Prospective evaluation of the sensitivity of physical examination in chest trauma. J Trauma. 2002;53(6):1135–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Jauhar S. The demise of the physical exam. N Engl J Med. 2006;354(6):548–51.CrossRefPubMedGoogle Scholar
  15. 15.
    Oliver CM, Hunter SA, Ikeda T, et al. Junior doctor skill in the art of physical examination: a retrospective study of the medical admission note over four decades. BMJ Open. 2013;3(4):e002257. doi: 10.1136/bmjopen-2012-002257.
  16. 16.
    Kong VY, Oosthuizen GV, Sartorius B, Bruce JL, Clarke DL. Penetrating cardiac injuries and the evolving management algorithm in the current era. J Surg Res. 2014. doi: 10.1016/j.jss.2014.09.027.

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, Nelson R Mandela School of MedicineUniversity of KwaZulu NatalDurbanSouth Africa
  2. 2.Discipline of Public Health Medicine, School of Nursing and Public HealthUniversity of KwaZulu NatalDurbanSouth Africa

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