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External validation of clinical decision rules for children with wrist trauma
Marjolein A M Mulders1, Monique M J Walenkamp2, Bente F H Dubois2
1Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. m.a.mulders@amc.nl.
Insights
Three non-validated clinical decision rules for pediatric wrist trauma show high sensitivity but low specificity. The validated Amsterdam Pediatric Wrist Rules offer a better balance, reducing radiographs by 22% without missing fractures.
Area of Science:
- Pediatric Emergency Medicine
- Radiology Decision Support
Background:
- Clinical decision rules (CDRs) are crucial for optimizing wrist radiography in children, aiming to reduce unnecessary imaging, waiting times, and healthcare costs.
- Accurate and efficient diagnostic pathways are essential in pediatric emergency settings to manage acute wrist trauma effectively.
Purpose of the Study:
- To identify and externally validate non-validated clinical decision rules for pediatric wrist trauma.
- To compare the performance of these rules against the established Amsterdam Pediatric Wrist Rules (APWR).
Main Methods:
- Systematic review of studies proposing clinical prediction or decision rules for acute pediatric wrist trauma.
- External validation of identified rules in an independent cohort of 379 children.
- Calculation of sensitivity, specificity, and predictive values for each rule.
Main Results:
- Three non-validated clinical decision rules were identified and validated.
- Post-validation, sensitivities ranged from 94% to 99%, with specificities between 11% and 26%.
- These rules could reduce radiography by 7-17% but might miss 1.4-5.7% of fractures; APWR achieved a 22% reduction without missing fractures.
Conclusions:
- Non-validated rules demonstrate high sensitivity but poor specificity for pediatric wrist fractures.
- The Amsterdam Pediatric Wrist Rules provide a more favorable balance of sensitivity and specificity, leading to a significant reduction in radiography.
- APWR is recommended for its effectiveness in reducing unnecessary wrist radiographs in children without compromising fracture detection.
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.
Materials And 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.
Conclusion:
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.
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