A validation study for a clinical decision rule for acute wrist injury.

Abstract

Purpose: Acute wrist injury is a common reason for visiting the emergency department. To date, there are no implemented clinical decision rules to predict a fracture in this group of patients. We previously identified six clinical predictors in adult patients with acute wrist trauma. The aim of this study was to validate these predictors as a decision rule in a validation cohort.

Methods: This prospective cohort study was conducted in the emergency department at five hospitals in the Netherlands and included adults with acute wrist injury. All collaborating physicians performed a standardized physical examination and data were collected in a case report form. The main outcome was defined as the radiographic presence of a wrist fracture. Six clinical variables that were significantly associated with a fracture (ρ < 0.01) were included in a model to develop the clinical decision rule.

Results: A total of 493 fractures in 724 patients were identified by radiographic assessment. Almost all of the clinical variables were associated with the presence of a fracture. Our decision rule had a sensitivity of 0.97 (95% CI 0.96-0.99) with a specificity of 0.26 (95% CI 0.20-0.32) in this validation cohort. Application of the decision rule resulted in a reduction in radiographic assessment rate of 10% at the cost of missing 2% of the fractures.

Conclusion: The decision rule showed a high sensitivity and low specificity, possible due to the high pre-test probability of a wrist fracture in the cohort. Our study needs further validation in other populations.