The Amsterdam wrist rules: The multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma

Background: Although only 39 % of patients with wrist trauma have sustained a fracture, the majority of patients is routinely referred for radiography. The purpose of this study was to derive and externally validate a clinical decision rule that selects patients with acute wrist trauma in the Emergency Department (ED) for radiography. Methods: This multicenter prospective study consisted of three components: (1) derivation of a clinical prediction model for detecting wrist fractures in patients following wrist trauma; (2) external validation of this model; and (3) design of a clinical decision rule. The study was conducted in the EDs of five Dutch hospitals: one academic hospital (derivation cohort) and four regional hospitals (external validation cohort). We included all adult patients with acute wrist trauma. The main outcome was fracture of the wrist (distal radius, distal ulna or carpal bones) diagnosed on conventional X-rays. Results: A total of 882 patients were analyzed; 487 in the derivation cohort and 395 in the validation cohort. We derived a clinical prediction model with eight variables: age; sex, swelling of the wrist; swelling of the anatomical snuffbox, visible deformation; distal radius tender to palpation; pain on radial deviation and painful axial compression of the thumb. The Area Under the Curve at external validation of this model was 0.81 (95 % CI: 0.77-0.85). The sensitivity and specificity of the Amsterdam Wrist Rules (AWR) in the external validation cohort were 98 % (95 % CI: 95-99 %) and 21 % (95 % CI: 15 %-28). The negative predictive value was 90 % (95 % CI: 81-99 %). Conclusions: The Amsterdam Wrist Rules is a clinical prediction rule with a high sensitivity and negative predictive value for fractures of the wrist. Although external validation showed low specificity and 100 % sensitivity could not be achieved, the Amsterdam Wrist Rules can provide physicians in the Emergency Department with a useful screening tool to select patients with acute wrist trauma for radiography. The upcoming implementation study will further reveal the impact of the Amsterdam Wrist Rules on the anticipated reduction of X-rays requested, missed fractures, Emergency Department waiting times and health care costs. Trial registration: This study was registered in the Dutch Trial Registry, reference number NTR2544 on October 1st, 2010

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

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. Materials and 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. Conclusion: The decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required

Routine versus on demand removal of the syndesmotic screw; A protocol for an international randomised controlled trial (RODEO-trial)

Background: Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome. Design: This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up. Discussion: If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs. Trial registration: This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov (NCT02896998) on July 15th 2016

The dangers of pets and horses, animal related injuries in the Emergency department

Introduction: Every year patients present to the emergency department due to bites, scratches and falls caused by animals. Although bite and scratch injuries have been described in literature, the exact number of patients that visit the emergency department due to all animal related injuries has never been described before. Methods: A retrospective analysis of all emergency department visits throughout a 1-year period was performed from April 2015 until March 2016. Results: 516 Patients were treated at the emergency department because of animal related injuries. Most were female and the median age was 38 years. The animals causing most injuries were horses, followed by dogs and cats. Animal related injuries more often caused fractures (n = 165) or contusions (n = 171) compared to wounds (n = 135). No lethal injuries were recorded. However, three animals did not survive the event. Conclusions: The incidence of animal related injuries is 2.8% and this is probably an underestimation. The injuries have noteworthy origins and have potentially severe physical injury as result. Awareness in the general population on the potential dangers of pets and horses could reduce the number and severity of animal related injuries. Keywords: Trauma, Injury, Animals, Emergency departmen

The Amsterdam Wrist Rules to reduce the need for radiography after a suspected distal radius fracture: an implementation study

Purpose: While most patients with wrist trauma are routinely referred for radiography, around 50% of these radiographs show no fracture. To avoid unnecessary radiographs, the Amsterdam Wrist Rules (AWR) have previously been developed and validated. The aim of the current study was to evaluate the effect of the implementation of the AWR at the Emergency Department (ED). Methods: In a before-and-after comparative prospective cohort study, all consecutive adult patients with acute wrist trauma presenting at the ED of four hospitals were included. Primary outcome was the number of wrist radiographs before and after implementation of the AWR. Secondary outcomes were the number of clinically relevant missed fractures, the overall length of stay in the ED, physician compliance regarding the AWR, and patient satisfaction and experience with the care received at the ED. Results: A total of 402 patients were included. The absolute reduction in wrist radiographs after implementation was 15% (p < 0.001). One clinically irrelevant fracture was missed. Non-fracture patients without wrist radiography due to the AWR spent 34 min less time in the ED compared with non-fracture patients who had a wrist radiograph (p = 0.015). The physicians adhered to the AWR in 36% of patients. Of all patients who did not receive a radiographic examination of the wrist, 87% were satisfied. Conclusion: Implementation of the AWR safely reduces the amount of wrist radiographs in selected patients and consequently reducing the length of stay in the ED

The Amsterdam Wrist Rules: how much money can they save?

Purpose: To allow physicians to be more selective in their request for a radiograph of the wrist and to potentially reduce costs, the Amsterdam Wrist Rules (AWR) have been developed, externally validated, and recently also implemented. The aim of this study was to conduct an incremental cost analysis and budget impact analysis of the implementation of the AWR at the emergency department (ED) in the Netherlands. Methods: A cost-minimisation analysis to determine the expected cost savings for implementation of the Amsterdam Wrist Rules. The incremental difference in costs before and after implementation of the AWR was based on the reduction in costs for radiographs, the cost savings due to reduction of ED consultation times and the costs of a re-evaluation appointment by a physician. Results: In the Netherlands, implementation of the AWR could potentially result in 6% cost savings per patient with a wrist injury. In addition, implementation of the AWR resulted in €203,510 cost savings annually nationwide. In the sensitivity analysis, an increase in physician compliance to 100% substantially increased the potential total amount of annual cost savings to €610,248, which is 6% of total costs before implementation. Variation in time spent at the ED, a decrease and increase in costs and patients presenting annually at the ED did not change the cost savings substantially. Conclusion: Implementation of the AWR has been shown to reduce direct and indirect costs and can, therefore, result in considerable savings of healthcare consumption and expenditure

Implementation of the Amsterdam Pediatric Wrist Rules

Background: The Amsterdam Pediatric Wrist Rules have been developed and validated to reduce wrist radiographs following wrist trauma in pediatric patients. However, the actual impact should be evaluated in an implementation study. Objective: To evaluate the effect of implementation of the Amsterdam Pediatric Wrist Rules at the emergency department. Materials and methods: A before-and-after comparative prospective cohort study was conducted, including all consecutive patients aged 3 to 18 years presenting at the emergency department with acute wrist trauma. The primary outcome was the difference in the number of wrist radiographs before and after implementation. Secondary outcomes were the number of clinically relevant missed fractures of the distal forearm, the difference in length of stay at the emergency department and physician compliance with the Amsterdam Pediatric Wrist Rules. Results: A total of 408 patients were included. The absolute reduction in radiographs was 19% compared to before implementation (chi-square test, P<0.001). Non-fracture patients who were discharged without a wrist radiograph had a 26-min shorter stay at the emergency department compared to patients who received a wrist radiograph (68 min vs. 94 min; Mann-Whitney U test, P=0.004). Eight fractures were missed following the recommendation of the Amsterdam Pediatric Wrist Rules. However, only four of them were clinically relevant. Conclusion: Implementing the Amsterdam Pediatric Wrist Rules resulted in a significant reduction in wrist radiographs and time spent at the emergency department. The Amsterdam Pediatric Wrist Rules were able to correctly identify 98% of all clinically relevant distal forearm fractures

Functional outcome of routine versus on-demand removal of the syndesmotic screw: a four-year follow-up

Aims: The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS). Methods: All patients included in the ‘ROutine vs on DEmand removal Of the syndesmotic screw’ (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups. Results: The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092). Conclusion: This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation. Cite this article: Bone Jt Open 2023;4(12):957–963