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A Clinical Decision Rule for the Use of Radiography in Acute Wrist Injury: Development and External Validation of the Amsterdam Wrist Rules
Monique M.J. Walenkamp, MD, MSc; J. Carel Goslings, MD, PhD; Niels W.L. Schep, MD, PhD, MSc
Trauma Unit, Deptartment of Surgery, Academic Medical Center, Amsterdam, Netherlands

Introduction: Wrist trauma is one of the most common Emergency Department (ED) attendances and in most hospitals, patients are routinely referred for radiography. There are no guidelines that indicate which patients require an X-ray of the wrist. A clinical decision rule that indicates if a patient requires radiography could avoid unnecessary exposure to radiation; decrease ED waiting times and reduce health care expenditure.

Methods: This cross-sectional study was conducted in the Emergency Departments of five Dutch hospitals: one academic hospital and four teaching hospitals. It consisted of two components: (1) development of a clinical prediction model; and (2) external validation of the model. We included all consecutive adult patients who presented at the ED with pain following wrist trauma. Patients were evaluated for 15 clinical variables including patient characteristics, mechanism of injury, physical examination and functional testing. The outcome measure was a fracture of the distal radius diagnosed on conventional x-rays at ED presentation. Data from the academic hospital were used to develop a prediction model. Subsequently, this model was validated in data from the other four hospitals to support general applicability.

Results: A total of


patients were analysed: 487 patients in the academic hospital and 398 patients in the other four hospitals. A clinical prediction model was developed that resulted in a model with the variables age; swelling of the distal radius; visible deformation; distal radius tender to palpation; painful ulnar deviation; dorsal flexion; palmar flexion; supination and a painful radioulnar ballottement test. This model showed an Area under the Receiver Operating Characteristics Curve (AUC) of 0.91 (95% CI: 0.89 - 0.94). The AUC of the external validation in the other four hospitals was 0.85 (95% CI: 0.81 - 0.89). From this model, a clinical decision rule was defined with a sensitivity and specificity of 97% (95% CI: 94% - 99%) and 30% (95% CI: 23% - 35%) for detecting fractures of distal radius.

Conclusion: The Amsterdam Wrist Rules provide an excellent tool in the Emergency Department to indicate which patients require an X-ray. If the Amsterdam Wrist Rules had been applied in the external validation cohort, an X-ray would have been requested for only 82.9% (330/ 398) of the patients instead of 100%. This is an absolute reduction of 17.1%. Applying the Amsterdam Wrist Rules to patients with wrist trauma in the Emergency Department could avoid a substantial number of unnecessary X-rays.

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