Annelie Slaar

Amsterdam wrist rules: A clinical decision aid

BackgroundAcute trauma of the wrist is one of the most frequent reasons for visiting the Emergency Department. These patients are routinely referred for radiological examination. Most X-rays however, do not reveal any fractures. A clinical decision rule determining the need for X-rays in patients with acute wrist trauma may help to percolate and select patients with fractures.Methods/DesignThis study will be a multi-center observational diagnostic study in which the data will be collected cross-sectionally. The study population will consist of all consecutive adult patients (≥18 years) presenting with acute wrist trauma at the Emergency Department in the participating hospitals.This research comprises two components: one study will be conducted to determine which clinical parameters are predictive for the presence of a distal radius fracture in adult patients presenting to the Emergency Department following acute wrist trauma. These clinical parameters are defined by trauma-mechanism, physical examination, and functional testing. This data will be collected in two of the three participating hospitals and will be assessed by using logistic regression modelling to estimate the regression coefficients after which a reduced model will be created by means of a log likelihood ratio test. The accuracy of the model will be estimated by a goodness of fit test and an ROC curve. The final model will be validated internally through bootstrapping and by shrinking it, an adjusted model will be generated.In the second component of this study, the developed prediction model will be validated in a new dataset consisting of a population of patients from the third hospital. If necessary, the model will be calibrated using the data from the validation study.DiscussionWrist trauma is frequently encountered at the Emergency Department. However, to this date, no decision rule regarding this type of trauma has been created. Ideally, radiographs are obtained of all patients entering one of the participating hospitals with trauma to the wrist. However, this is ethically and logistically not feasible and one could argue that patients, for whom no radiography is required according to their physician, are not suspected of having a distal radius fracture and thus are not part of the domain.Trial registrationThis study is registered at the Netherlands Trial Register (NTR 2544) and was granted permission by the Medical Ethical Committee of the Academic Medical Center Amsterdam on 06-01-2011.

The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma

BackgroundAlthough only 39xa0% of patients with wrist trauma have sustained a fracture, the majority of patients is routinely referred for radiography. The purpose of this study was to derive and externally validate a clinical decision rule that selects patients with acute wrist trauma in the Emergency Department (ED) for radiography.MethodsThis multicenter prospective study consisted of three components: (1) derivation of a clinical prediction model for detecting wrist fractures in patients following wrist trauma; (2) external validation of this model; and (3) design of a clinical decision rule. The study was conducted in the EDs of five Dutch hospitals: one academic hospital (derivation cohort) and four regional hospitals (external validation cohort). We included all adult patients with acute wrist trauma. The main outcome was fracture of the wrist (distal radius, distal ulna or carpal bones) diagnosed on conventional X-rays.ResultsA total of 882 patients were analyzed; 487 in the derivation cohort and 395 in the validation cohort. We derived a clinical prediction model with eight variables: age; sex, swelling of the wrist; swelling of the anatomical snuffbox, visible deformation; distal radius tender to palpation; pain on radial deviation and painful axial compression of the thumb. The Area Under the Curve at external validation of this model was 0.81 (95xa0% CI: 0.77–0.85). The sensitivity and specificity of the Amsterdam Wrist Rules (AWR) in the external validation cohort were 98xa0% (95xa0% CI: 95–99xa0%) and 21xa0% (95xa0% CI: 15xa0%–28). The negative predictive value was 90xa0% (95xa0% CI: 81–99xa0%).ConclusionsThe Amsterdam Wrist Rules is a clinical prediction rule with a high sensitivity and negative predictive value for fractures of the wrist. Although external validation showed low specificity and 100xa0% sensitivity could not be achieved, the Amsterdam Wrist Rules can provide physicians in the Emergency Department with a useful screening tool to select patients with acute wrist trauma for radiography. The upcoming implementation study will further reveal the impact of the Amsterdam Wrist Rules on the anticipated reduction of X-rays requested, missed fractures, Emergency Department waiting times and health care costs.Trial registrationThis study was registered in the Dutch Trial Registry, reference number NTR2544 on October 1st, 2010.

The role of plain radiography in paediatric wrist trauma

ObjectivesAcute wrist trauma in children is one of the most frequent reasons for visiting the emergency department (ED). Radiographic imaging in children with wrist trauma is mostly performed routinely to confirm or rule out a fracture. The aim of this study was to determine how many radiographs of the wrist show a fracture in children following wrist trauma.MethodsA retrospective cohort study was performed in three Dutch hospitals from 2009–2010. Data were extracted from patient records and radiographic reports.ResultsOf the 1,223 children who presented at the ED after a wrist trauma, 51 % had a wrist fracture. The peak incidence of having a wrist fracture was at the age of 10xa0years; 65xa0% of the children younger than 10xa0years of age had a wrist fracture. Of all the patients without a wrist fracture, 74xa0% were older than 10xa0years of age.ConclusionAlmost half of the paediatric patients with a trauma of the wrist had normal radiographs. The development of a clinical decision rule to determine when a radiograph of the wrist is indicated following acute wrist trauma is needed. This could likely reduce the number of radiographs.Main MessagesFifty-one percent of the children with wrist trauma have a wrist fracture.Peak incidence of having a wrist fracture is at the age of 10xa0years.Sixty-five percent of the children younger than 10xa0years of age had a wrist fracture.Of all the patients without a wrist fracture, 74xa0% were older than 10xa0years of age.The development of a clinical decision rule to reduce the number of radiographs is needed.

A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules

BackgroundIn most hospitals, children with acute wrist trauma are routinely referred for radiography.ObjectiveTo develop and validate a clinical decision rule to decide whether radiography in children with wrist trauma is required.Materials and methodsWe prospectively developed and validated a clinical decision rule in two study populations. All children who presented in the emergency department of four hospitals with pain following wrist trauma were included and evaluated for 18 clinical variables. The outcome was a wrist fracture diagnosed by plain radiography.ResultsIncluded in the study were 787 children. The prediction model consisted of six variables: age, swelling of the distal radius, visible deformation, distal radius tender to palpation, anatomical snuffbox tender to palpation, and painful or abnormal supination. The model showed an area under the receiver operator characteristics curve of 0.79 (95% CI: 0.76-0.83). The sensitivity and specificity were 95.9% and 37.3%, respectively. The use of this model would have resulted in a 22% absolute reduction of radiographic examinations. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7-8.3%) would have been missed using the decision model.ConclusionThe decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required.

External validation of clinical decision rules for children with wrist trauma

BackgroundClinical decision rules help to avoid potentially unnecessary radiographs of the wrist, reduce waiting times and save costs.ObjectiveThe primary aim of this study was to provide an overview of all existing non-validated clinical decision rules for wrist trauma in children and to externally validate these rules in a different cohort of patients. Secondarily, we aimed to compare the performance of these rules with the validated Amsterdam Pediatric Wrist Rules.Materials and methodsWe included all studies that proposed a clinical prediction or decision rule in children presenting at the emergency department with acute wrist trauma. We performed external validation within a cohort of 379 children. We also calculated the sensitivity, specificity, negative predictive value and positive predictive value of each decision rule.ResultsWe included three clinical decision rules. The sensitivity and specificity of all clinical decision rules after external validation were between 94% and 99%, and 11% and 26%, respectively. After external validation 7% to 17% less radiographs would be ordered and 1.4% to 5.7% of all fractures would be missed. Compared to the Amsterdam Pediatric Wrist Rules only one of the three other rules had a higher sensitivity; however both the specificity and the reduction in requested radiographs were lower in the other three rules.ConclusionThe sensitivity of the three non-validated clinical decision rules is high. However the specificity and the reduction in number of requested radiographs are low. In contrast, the validated Amsterdam Pediatric Wrist Rules has an acceptable sensitivity and the greatest reduction in radiographs, at 22%, without missing any clinically relevant fractures.

Plain radiography in children with spoke wheel injury: A retrospective cohort study

BACKGROUND AND PURPOSEnBicycle spoke injury (BSI) mostly occurs in children as a result of entrapment of the leg in the bicycle spokes. No guideline or protocol exists that defines what type of radiography is indicated to diagnose or rule out a fracture commonly associated with these injuries. The aim of this study was (1) to evaluate the type of radiographs that are obtained in children with BSI, (2) to assess in which anatomical regions fractures occur and (3) to evaluate on which radiographs a fracture can be detected in children with BSI.nnnPATIENTS AND METHODSnA retrospective cohort study was performed in paediatric patients presenting at the Emergency Department (ED) of a university hospital with a paediatric surgery department between June 2008 and December 2013.nnnRESULTSnIn 99 of the 320 children (31.4%) evaluated with radiography following BSI a fracture was diagnosed. In almost two third of the patients (63%) radiographic imaging of two or more anatomical regions was performed. In 98 children (99%) the fracture was located at the distal tibia or fibula. All fractures were diagnosed on a radiograph of the ankle or lower leg (including the ankle region). No fractures of the foot were diagnosed.nnnCONCLUSIONnWe suggest that in children with a clinical suspicion of a fracture at the ankle region, in which no fracture is seen at the radiograph of the ankle, no additional radiographs are necessary.

Implementation of the Amsterdam Pediatric Wrist Rules

BackgroundThe Amsterdam Pediatric Wrist Rules have been developed and validated to reduce wrist radiographs following wrist trauma in pediatric patients. However, the actual impact should be evaluated in an implementation study.ObjectiveTo evaluate the effect of implementation of the Amsterdam Pediatric Wrist Rules at the emergency department.Materials and methodsA before-and-after comparative prospective cohort study was conducted, including all consecutive patients aged 3 to 18xa0years presenting at the emergency department with acute wrist trauma. The primary outcome was the difference in the number of wrist radiographs before and after implementation. Secondary outcomes were the number of clinically relevant missed fractures of the distal forearm, the difference in length of stay at the emergency department and physician compliance with the Amsterdam Pediatric Wrist Rules.ResultsA total of 408 patients were included. The absolute reduction in radiographs was 19% compared to before implementation (chi-square test, P<0.001). Non-fracture patients who were discharged without a wrist radiograph had a 26-min shorter stay at the emergency department compared to patients who received a wrist radiograph (68xa0min vs. 94xa0min; Mann-Whitney U test, P=0.004). Eight fractures were missed following the recommendation of the Amsterdam Pediatric Wrist Rules. However, only four of them were clinically relevant.ConclusionImplementing the Amsterdam Pediatric Wrist Rules resulted in a significant reduction in wrist radiographs and time spent at the emergency department. The Amsterdam Pediatric Wrist Rules were able to correctly identify 98% of all clinically relevant distal forearm fractures.

Erratum to: External validation of clinical decision rules for children with wrist trauma

The published version of this article contained mistakes. Table 6 was published with incorrect table heading and table legend. This has now been corrected.

Adherence to the guidelines of paediatric cervical spine clearance in a level I trauma centre: A single centre experience.

INTRODUCTIONnInternational guidelines define if and what type of radiography is advised in children to clear the cervical spine (C-spine). However, adherence to these guidelines has never been evaluated in a paediatric population. Therefore, we wanted to assess the adherence to the guidelines for C-spine clearance in a level-one trauma centre.nnnMETHODSnWe retrospectively included all children, presented at the ED between January 2006 and December 2013, in whom radiographic imaging of the C-spine was obtained following blunt trauma. Primary outcome was the adherence to the international guidelines with regard to (1) if the indication for radiographic imaging was correct and (2) if the type of radiographic imaging was correct.nnnRESULTSnIncluded were 573 patients; 336 boys (58.7%). Median age was 11 years (IQR 5.25-15). The indication for radiographic imaging was correct in all cases. The type of primary imaging modality was concordant with the guidelines in 99,7%. In 41% of the cases supplementary radiographs were made. The most common supplementary view was the odontoid. In 15% an incomplete set of radiographs was obtained.nnnCONCLUSIONnThe adherence to the international guidelines when to obtain radiographic imaging was 100%. However, in a large proportion of patients (56%), not the recommended number of radiographs was obtained.

Correction: Amsterdam wrist rules: a clinical decision aid

The name of one of the authors of this manuscript (1) was misspelled. The correct name is: J. Carel Goslings. We regret any inconvenience this error has caused.