Abstract
BackgroundThe 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.ObjectiveTo evaluate the effect of implementation of the Amsterdam Pediatric Wrist Rules at the emergency department.Materials and methodsA 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.ResultsA 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.ConclusionImplementing 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.
Highlights
Study populationA wrist fracture is one of the most common fractures in children, accounting for 20–36% of all pediatric fractures [1,2,3]
Implementation of the Amsterdam Pediatric Wrist Rules could potentially result in an 19% reduction in wrist radiographs, and a 26-min reduction in time spent at the emergency department for non-fracture patients who had no wrist radiograph
Counselling a patient will take only a few minutes, while conducting and reviewing a radiograph, and explaining the findings to the patient takes more time. This was confirmed by the significant reduction of 26 min in time spent at the emergency department for non-fracture patients in whom no radiograph was performed compared to non-fracture patients who had a wrist radiograph
Summary
Study populationA wrist fracture is one of the most common fractures in children, accounting for 20–36% of all pediatric fractures [1,2,3]. The incidence of distal forearm fractures is increasing [4, 5], resulting in an increasing number of emergency department presentations and requested radiographs and, rising health care costs [6]. To be more selective in the request for a radiograph and support physicians, the Amsterdam Pediatric Wrist Rules were developed and externally validated. Based on age and a number of clinical variables, the Amsterdam Pediatric Wrist Rules calculates the probability of a distal forearm fracture in children. The Amsterdam Pediatric Wrist Rules have been shown to have an acceptable sensitivity and a reduction in radiographs of 22% without missing any clinically relevant fractures [9]. The Amsterdam Pediatric Wrist Rules can potentially reduce the number of requested radiographs, reduce the length of stay at the emergency department, and thereby potentially reduce health care costs. The actual impact should be evaluated in an implementation study
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