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
Abstract: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 outcom… Show more
“…1). One of these studies was the previously validated Amsterdam Pediatric Wrist Rules study [19]. This resulted in three other decision rules for children with wrist trauma.Fig.…”
Section: Resultsmentioning
confidence: 99%
“…At the same time, in external validation this rule missed 4.1% of fractures, although none of these was clinically relevant [19]. The sensitivity of the Amsterdam Pediatric Wrist Rules was 96% (95% CI: 92–98%) and the specificity was 37% (95% CI: 31–44%).…”
Section: Discussionmentioning
confidence: 99%
“…One of these decision rules is the Amsterdam Pediatric Wrist Rules [19]. The Amsterdam Pediatric Wrist Rules is a clinical decision rule that aids in determining the need for a radiograph of the wrist in children, based on age and variables visible deformation, swelling of the distal radius, bone tenderness of the distal radius and the anatomical snuff box, and painful supination.…”
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.
“…1). One of these studies was the previously validated Amsterdam Pediatric Wrist Rules study [19]. This resulted in three other decision rules for children with wrist trauma.Fig.…”
Section: Resultsmentioning
confidence: 99%
“…At the same time, in external validation this rule missed 4.1% of fractures, although none of these was clinically relevant [19]. The sensitivity of the Amsterdam Pediatric Wrist Rules was 96% (95% CI: 92–98%) and the specificity was 37% (95% CI: 31–44%).…”
Section: Discussionmentioning
confidence: 99%
“…One of these decision rules is the Amsterdam Pediatric Wrist Rules [19]. The Amsterdam Pediatric Wrist Rules is a clinical decision rule that aids in determining the need for a radiograph of the wrist in children, based on age and variables visible deformation, swelling of the distal radius, bone tenderness of the distal radius and the anatomical snuff box, and painful supination.…”
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.
“…The inclusion of all acute wrist injuries ensured that all scaphoid fractures were included in the analysis to get an accurate representation of clinical practice. The statistical models have been thoroughly tested, for this study as well as previously for the Amsterdam Wrist Rules [13,20].…”
Introduction The aim of this study was to develop and validate an easy to use clinical decision rule, applicable in the ED that limits the number of unnecessary cast immobilizations and diagnostic follow-up in suspected scaphoid injury, without increasing the risk of missing fractures. Methods A prospective multicenter study was conducted that consisted of three components: (1) derivation of a clinical prediction model for detecting scaphoid fractures in adult patients following wrist trauma; (2) internal validation of the model;(3) design of a clinical decision rule. The predictors used were: sex, age, swelling of the anatomic snuffbox, tenderness in the anatomic snuffbox, scaphoid tubercle tenderness, painful ulnar deviation and painful axial thumb compression. The outcome measure was the presence of a scaphoid fracture, diagnosed on either initial radiographs or during re-evaluation after 1-2 weeks or on additional imaging (radiographs/MRI/CT). After multivariate logistic regression analysis and bootstrapping, the regression coefficient for each significant predictor was calculated. The effect of the rule was determined by calculating the number of missed scaphoid fractures and reduction of suspected fractures that required a cast. Results A consecutive series of 893 patients with acute wrist injury was included. Sixty-eight patients (7.6%) were diagnosed with a scaphoid fracture. The final prediction rule incorporated sex, swelling of the anatomic snuffbox, tenderness in the anatomic snuffbox, painful ulnar deviation and painful axial thumb compression. Internal validation of the prediction rule showed a sensitivity of 97% and a specificity of 20%. Using this rule, a 15% reduction in unnecessary immobilization and imaging could be achieved with a 50% decreased risk of missing a fracture compared with current clinical practice. Conclusions This dataset provided a simple clinical decision rule for scaphoid fractures following acute wrist injury that limits unnecessary immobilization and imaging with a decreased risk of missing a fracture compared to current clinical practice. Clinical prediction rule 1/(1 + EXP (−(0.649662618 × if man) + (0.51353467826 × if swelling anatomic snuffbox) + (−0.79038263985 × if painful palpation anatomic snuffbox) + (0.57681198857 × if painful ulnar deviation) + (0.66499549728 × if painful thumb compression)−1.685). Trial registration Trial register NTR 2544, www.trial regis ter.nl.Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
“…A pontos diagnózis felállítása az esetek túlnyomó részében röntgen-(RTG-) képalkotással tör-ténik [4,5]. A hagyományos kétirányú RTG-felvétel elhanyagolható egészségügyi kockázatot jelent, ugyanakkor világszerte hangsúlyozott törekvés az ionizáló sugárzás lehetőség szerinti minimalizálása [6,7].…”
Bevezetés és célkitűzés:Prospektív tanulmányunk célja a gyermekkori csuklótörések ultrahang-diagnosztikájának ismertetése és két mozgásszervi centrum eredményének bemutatása. Módszer: 2011 januárja és 2015 decembere között 467, 1-15 év közötti gyermek ultrahangvizsgálatát végeztük el. Valamennyi gyermek zárt sérülést szenvedett el és nyitott epiphysisfugával rendelkezett. Az ultrahangvizsgálatot rezidensek és ortopéd-traumatológus, illetve gyermeksebész szakorvosok végezték közvetlenül az elsődleges fizikális vizsgálatot követően, 7-14 MHz frekvenciatartományú lineáris transzducerekkel. Az eredményeket hagyományos kétirányú csukló-röntgenfelvételekkel hasonlítottuk össze. Eredmények: 97%-os szenzitivitást és 96%-os specificitást találtunk. Elmozdulással és komolyabb klinikai konzekvenciával járó törések ultrahanggal is mind felismerésre kerültek. Következtetés: A mozgásszervi ultrahangvizsgálat a gyermekkori csuklótáji törések igazolásának vagy kizárásának rendkívül hatékony eszköze a napi gyakorlatban. Orv Hetil. 2017; 158(24): 944-948.
Kulcsszavak: ultrahang, gyermekkor, csuklótörés
Ultrasonographic diagnosis of distal pediatric forearm fracturesIntroduction and aim: The aim of our prospective study was to evaluate the effectivity of sonographic diagnosis of pediatric wrist fractures and analyzing the results of two pediatric musculoskeletal centers. Method: Between 2011 January and 2015 December 467 children aged 0-15 with closed wrist injuries and open growth plates were sonographically and radiologically evaluated by an orthopaedic surgeon or a resident in trainee. Sonography was performed immediately after physical examination with linear probes of 7-14 Mhz frequency. Results were compared to conventional two plane wrist x-rays. Results: We found 97 sensitivity and 96 specificity of the sonographic evaluation. Fractures with dislocations and more serious clinical consequences were never missed. Conclusion: Musculoskeletal ultrasound is a very effective tool in daily routine for diagnosing or excluding pediatric wrist fractures.
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