title: A multicentre cross-sectional study to examine physicians' ability to rule out a distal radius fracture based on clinical findings.
abstract: OBJECTIVE
  To study current use of radiography in patients with wrist trauma and examine physicians' ability to rule out a distal radius fracture based on their physical findings.
  
  
  METHODS
  We performed a multicentre cross-sectional observational study in five Emergency Departments (ED) between November 2010 and June 2014 and included all consecutive adult patients with wrist trauma. Physicians were asked to perform a standardized examination of the wrist and to subsequently indicate the probability of a distal radius fracture.
  
  
  RESULTS
  The majority of the 924 included patients were referred for radiography (99.6 %). Of the 920 patients that were imaged, 402 (44 %) had sustained a distal radius fracture, 82 (9 %) an isolated carpal fracture and 12 (1 %) an isolated ulna fracture. Overall, physicians were able to accurately discriminate between patients with and without a distal radius fracture (area under the receiver operating characteristics curve: 0.87, 95 % CI 0.85-0.89). Physicians were absolutely certain of their clinical diagnosis in 180 patients (19 %), for whom they indicated either a 0 % or a 100 % probability. In these patients, physicians showed a 99 % sensitivity (95 % CI 98-100) and 67 % specificity (95 % CI 53-80) for predicting a distal radius fracture.
  
  
  CONCLUSIONS
  Although physicians in the ED are able to accurately discriminate between patients with and without a distal radius fracture based on their physical findings, they were only completely certain of their diagnosis in 19 % of the patients. A validated clinical decision rule could reinforce physician's clinical judgment and support them in their decision not to routinely request radiography.
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. m.m.walenkamp@amc.nl.
authors.forename: M M J
authors.initials: MM
authors.lastname: Walenkamp
authors.affiliation: Department of Orthopaedic Surgery, Columbia University Medical Center, 622 West 168th Street, New York, NY, 10032, USA.
authors.forename: M P
authors.initials: MP
authors.lastname: Rosenwasser
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
authors.forename: J C
authors.initials: JC
authors.lastname: Goslings
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
authors.forename: N W L
authors.initials: NW
authors.lastname: Schep
mesh_terms: D000328:Adult; D000066491:Clinical Decision-Making / Q000379:methods*; D003430:Cross-Sectional Studies; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010808:Physical Examination / Q000379:methods; D012372:ROC Curve; D011859:Radiography / Q000379:methods*; D011885:Radius Fractures / Q000175:diagnosis / Q000000981:diagnostic imaging; D014954:Wrist Injuries / Q000175:diagnosis / Q000000981:diagnostic imaging
keywords: Clinical decision rule; Diagnostic accuracy; Distal radius fracture; Emergency medicine; Physical examination; Wrist trauma