Clinical validation of the "Straight-Leg-Evaluation-Trauma-Test" (SILENT) as a rapid assessment tool for injuries of the lower extremity in trauma bay patients

Till Berk; Valentin Neuhaus; Catalina Nierlich; Zsolt J Balogh; Felix Karl-Ludwig Klingebiel; Yannik Kalbas; Hans-Christoph Pape; Sascha Halvachizadeh

doi:10.1007/s00068-023-02437-z

Clinical validation of the "Straight-Leg-Evaluation-Trauma-Test" (SILENT) as a rapid assessment tool for injuries of the lower extremity in trauma bay patients

Eur J Trauma Emerg Surg. 2024 Jan 23. doi: 10.1007/s00068-023-02437-z. Online ahead of print.

Authors

Till Berk^{1

2

3}, Valentin Neuhaus^{4

5

6}, Catalina Nierlich^{5

6}, Zsolt J Balogh⁷, Felix Karl-Ludwig Klingebiel^{4

5

6}, Yannik Kalbas^{4

5

6}, Hans-Christoph Pape^{4

5

6}, Sascha Halvachizadeh^{4

5

6}

Affiliations

¹ Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. Till.Berk@usz.ch.
² Faculty of Medicine, University of Zurich, Raemistrasse 71, 8006, Zurich, Switzerland. Till.Berk@usz.ch.
³ Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Sternwartstrasse 14, 8091, Zurich, Switzerland. Till.Berk@usz.ch.
⁴ Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
⁵ Faculty of Medicine, University of Zurich, Raemistrasse 71, 8006, Zurich, Switzerland.
⁶ Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Sternwartstrasse 14, 8091, Zurich, Switzerland.
⁷ Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia.

PMID: 38261076
DOI: 10.1007/s00068-023-02437-z

Abstract

Purpose: Clinical assessment of the major trauma patient follows international validated guidelines without standardized trauma-specific assessment of the lower extremities for injuries. This study aimed to validate a novel clinical test for lower extremity evaluation during trauma resuscitation phase.

Methods: This diagnostic, prognostic observational cohort study was performed on trauma patient treated at one level I trauma center between Mar 2022 and Mar 2023. The Straight-Leg-Evaluation-Trauma (SILENT) test follows three steps during the primary survey: inspection for obvious fractures (e.g., open fracture), active elevation of the leg, and cautious elevation of the lower extremity from the heel. SILENT was considered positive when obvious fracture was present and painful or pathological mobility was observed. The SILENT test was compared with standardized radiographs (CT scan or X-ray) as the reference test for fractures. Statistical analysis included sensitivity, specificity, and receiver operating characteristic testing.

Results: 403 trauma bay patients were included, mean age 51.6 (SD 21.2) years with 83 fractures of the lower extremity and 27 pelvic/acetabular fractures. Overall sensitivity was 75% (95%CI 64 to 84%), and overall specificity was 99% (95%CI 97 to 100%). Highest sensitivity was for detection of tibia fractures (93%, 95%CI 77 to 99%). Sensitivity of SILENT was higher in the unconscious patient (96%, 95%CI 78 to 100%) with a near 100% specificity. AUC was highest for tibia fractures (0.96, 95%CI 0.92 to 1.0) followed by femur fractures (0.92, 95%CI 0.84 to 0.99).

Conclusion: The SILENT test is a clinical applicable and feasible rule-out test for relevant injuries of the lower extremity. A negative SILENT test of the femur or the tibia might reduce the requirement of additional radiological imaging. Further large-scale prospective studies might be required to corroborate the beneficial effects of the SILENT test.

Keywords: ATLS; Physical examination; Primary survey; SILENT test; Trauma bay.