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

Monique M J Walenkamp, Abdelali Bentohami, Annelie Slaar, M Suzan H Beerekamp, Mario Maas, L Cara Jager, Nico L Sosef, Romuald van Velde, Jan M Ultee, Ewout W Steyerberg, J Carel Goslings, Niels W L Schep, Monique M J Walenkamp, Abdelali Bentohami, Annelie Slaar, M Suzan H Beerekamp, Mario Maas, L Cara Jager, Nico L Sosef, Romuald van Velde, Jan M Ultee, Ewout W Steyerberg, J Carel Goslings, Niels W L Schep

Abstract

Background: Although only 39 % 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.

Methods: This 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.

Results: A 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 (95 % CI: 0.77-0.85). The sensitivity and specificity of the Amsterdam Wrist Rules (AWR) in the external validation cohort were 98 % (95 % CI: 95-99 %) and 21 % (95 % CI: 15 %-28). The negative predictive value was 90 % (95 % CI: 81-99 %).

Conclusions: The 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 100 % 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 registration: This study was registered in the Dutch Trial Registry, reference number NTR2544 on October 1(st), 2010.

Figures

Fig. 1
Fig. 1
Flowchart
Fig. 2
Fig. 2
A screen shot of the smart phone application that will be used during the implementation study. After entering the clinical findings, the application will calculate the probability of a distal radius fracture using the formula depicted in Table 1. If the probability of a distal radius fracture is

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