title: 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: BACKGROUND
  In most hospitals, children with acute wrist trauma are routinely referred for radiography.
  
  
  OBJECTIVE
  To develop and validate a clinical decision rule to decide whether radiography in children with wrist trauma is required.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  The decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required.
authors: Department of Radiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands. a.slaar@amc.nl.
authors: Annelie
authors: A
authors: Slaar
authors: Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors: Monique M J
authors: MM
authors: Walenkamp
authors: Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors: Abdelali
authors: A
authors: Bentohami
authors: Department of Radiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
authors: Mario
authors: M
authors: Maas
authors: Department of Radiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
authors: Rick R
authors: RR
authors: van Rijn
authors: Department of Public Health, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands.
authors: Ewout W
authors: EW
authors: Steyerberg
authors: Emergency Department, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors: L Cara
authors: LC
authors: Jager
authors: Department of Surgery, Spaarne Hospital, Hoofddorp, The Netherlands.
authors: Nico L
authors: NL
authors: Sosef
authors: Department of Surgery, Tergooi Hospitals, Hilversum, The Netherlands.
authors: Romuald
authors: R
authors: van Velde
authors: Department of Surgery, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands.
authors: Jan M
authors: JM
authors: Ultee
authors: Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors: J Carel
authors: JC
authors: Goslings
authors: Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.|Department of Surgery, Maasstadziekenhuis Rotterdam, Rotterdam, The Netherlands.
authors: Niels W L
authors: NW
authors: Schep
mesh_terms: D000208:Acute Disease; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D000066491:Clinical Decision-Making; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009426:Netherlands; D010372:Pediatrics / Q000592:standards*; D017410:Practice Guidelines as Topic; D011857:Radiographic Image Interpretation, Computer-Assisted / Q000592:standards; D011859:Radiography / Q000592:standards*; D011885:Radius Fractures / Q000000981:diagnostic imaging*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014954:Wrist Injuries / Q000000981:diagnostic imaging*
keywords: Child; Clinical decision rule; Distal forearm fracture; Multicenter prospective study design; Radiography; Trauma; Wrist