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

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

In most hospitals, children with acute wrist trauma are routinely referred for radiography. To develop and validate a clinical decision rule to decide whether radiography in children with wrist trauma is required. We 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. Included 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. The decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required.