title: External validation of clinical decision rules for children with wrist trauma.
abstract: BACKGROUND
  Clinical decision rules help to avoid potentially unnecessary radiographs of the wrist, reduce waiting times and save costs.
  
  
  OBJECTIVE
  The 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.
  
  
  METHODS
  We 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.
  
  
  RESULTS
  We 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.
  
  
  CONCLUSIONS
  The 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.
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. m.a.mulders@amc.nl.
authors.forename: Marjolein A M
authors.initials: MA
authors.lastname: Mulders
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
authors.forename: Monique M J
authors.initials: MM
authors.lastname: Walenkamp
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
authors.forename: Bente F H
authors.initials: BF
authors.lastname: Dubois
authors.affiliation: Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Annelie
authors.initials: A
authors.lastname: Slaar
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
authors.forename: J Carel
authors.initials: JC
authors.lastname: Goslings
authors.affiliation: Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands.
authors.forename: Niels W L
authors.initials: NW
authors.lastname: Schep
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis*; D006801:Humans; D008297:Male; D012680:Sensitivity and Specificity; D014954:Wrist Injuries / Q000175:diagnosis*
keywords: Adolescent; Child; Decision rule; Distal radius; Fracture; Trauma; Wrist