Pain has limited predictive value for fractures following falls in older people: insight from a retrospective study

BACKGROUND: In the emergency department (ED), decisions regarding radiological imaging for older patients who have experienced low-energy falls (LEF) are frequently complicated by inconsistencies between the reported mechanism of injury, the patients' symptoms, and the findings on physical examination. Our study aimed to investigate the coherence between physician-documented complaints, the implementation of radiological imaging and the diagnosis of fractures of the vertebral column, rib cage and pelvic ring. METHODS: This is a secondary analysis of a retrospective consecutive sample of 2882 patients presenting with LEF to two urban Level I trauma centers between 1 January 2016 and 31 December 2016, who underwent radiological imaging to diagnose their fractures. Physician-documented complaints were abstracted from electronic health records. RESULTS: A total of 2882 patients were included. Mild signs of concussion (e.g. headache) (22.0%), extremity pain (18.0%) and pain of the pelvic ring (14.2%) occurred most frequently. Physician-documented complaints were significantly associated with radiological imaging in the respective regions. True prevalence of fractures ranged from 0.14 (95%CI: 0.09, 0.20) in the cervical spine to 0.36 (95%CI: 0.30, 0.41) in the pelvic ring. The sensitivity of documented pain for fractures ranged from 0.78 (95%CI: 0.56, 0.93) in the thoracic spine to 0.98 in the rib cage (95%CI: 0.88, 1.00) and the pelvic ring (95%CI: 0.94, 1.00). Specificity was poor to moderate in all regions of interest. Positive likelihood ratios (LR+) were of poor value, ranging from 1.48 (95%CI: 1.09, 2.02) in the thoracic spine to 1.08 (95%CI: 1.03, 1.13) in the pelvic ring. Negative likelihood ratios (LR-) were of moderate to good value, ranging from 0.07 in the rib cage (95%CI: 0.01, 0.50) to 0.46 in the thoracic spine (95%CI: 0.20, 1.04). Area under the curve (AUC) values ranged from 0.51 (95%CI: 0.48-0.54) for the lumbar spine to 0.62 (95%CI: 0.59-0.65) for the rib cage. CONCLUSION: The presence of physician-documented complaints pertaining to the trunk skeleton have a relevant probability of triggering imaging studies in older persons with LEF in the ED. Nevertheless, these complaints do not safely enable discrimination between individuals with and without fractures and are of limited value modifying the subsequent diagnostic imaging process.