Dataset Information

Implementation of the Amsterdam Pediatric Wrist Rules.

ABSTRACT: 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.

SUBMITTER: Mulders MAM

PROVIDER: S-EPMC6153883 | biostudies-other | 2018 Jul

REPOSITORIES: biostudies-other

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Implementation of the Amsterdam Pediatric Wrist Rules.

Mulders Marjolein A M MAM Walenkamp Monique M J MMJ Slaar Annelie A Ouwehand Frank F Sosef Nico L NL van Velde Romuald R Goslings J Carel JC Schep Niels W L NWL

Pediatric radiology 20180710 11

<h4>Background</h4>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.<h4>Objective</h4>To evaluate the effect of implementation of the Amsterdam Pediatric Wrist Rules at the emergency department.<h4>Materials and methods</h4>A before-and-after comparative prospective cohort study was conducted, including all consecutive patients a ...[more]

PMID: 29992444

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Project description:BackgroundAcute trauma of the wrist is one of the most frequent reasons for visiting the Emergency Department. These patients are routinely referred for radiological examination. Most X-rays however, do not reveal any fractures. A clinical decision rule determining the need for X-rays in patients with acute wrist trauma may help to percolate and select patients with fractures.Methods/designThis study will be a multi-center observational diagnostic study in which the data will be collected cross-sectionally. The study population will consist of all consecutive adult patients (?18 years) presenting with acute wrist trauma at the Emergency Department in the participating hospitals. This research comprises two components: one study will be conducted to determine which clinical parameters are predictive for the presence of a distal radius fracture in adult patients presenting to the Emergency Department following acute wrist trauma. These clinical parameters are defined by trauma-mechanism, physical examination, and functional testing. This data will be collected in two of the three participating hospitals and will be assessed by using logistic regression modelling to estimate the regression coefficients after which a reduced model will be created by means of a log likelihood ratio test. The accuracy of the model will be estimated by a goodness of fit test and an ROC curve. The final model will be validated internally through bootstrapping and by shrinking it, an adjusted model will be generated. In the second component of this study, the developed prediction model will be validated in a new dataset consisting of a population of patients from the third hospital. If necessary, the model will be calibrated using the data from the validation study.DiscussionWrist trauma is frequently encountered at the Emergency Department. However, to this date, no decision rule regarding this type of trauma has been created. Ideally, radiographs are obtained of all patients entering one of the participating hospitals with trauma to the wrist. However, this is ethically and logistically not feasible and one could argue that patients, for whom no radiography is required according to their physician, are not suspected of having a distal radius fracture and thus are not part of the domain.Trial registrationThis study is registered at the Netherlands Trial Register (NTR 2544) and was granted permission by the Medical Ethical Committee of the Academic Medical Center Amsterdam on 06-01-2011.

Project description:IntroductionThe way strength recovers after reduction of pediatric fractures of the upper extremity has not previously been the specific scope of research. This is remarkable, since strength measurements are often used as an outcome measure in studies on trauma of the upper extremity. The aim of this study was to evaluate how strength recovers after sustainment of fractures of the forearm, wrist or hand treated by closed or open reduction in children and adolescents in the first 6 months after trauma. How much strength is lost at 6 weeks, 3 months and 6 months after trauma, and is this loss significant? Are there differences in the pattern of recovery between children who underwent a different treatment? And finally, which of the following factors are associated with an increase in the ratio between affected grip strength and expected strength: type of fracture, cast immobilization, occurrence of complications, and degree of pain?DesignProspective observational study.ParticipantsChildren and adolescents aged 4-18 years with a reduced fracture of the forearm, wrist or hand.MethodsGrip strength, key grip and three-jaw chuck grip were measured twice in each hand 6 weeks, 3 months and 6 months after trauma. Details on fracture type and location, treatment received, cast immobilization and complications were obtained. Hand-dominance and pain were verbally confirmed.ResultsLoss of strength was more prominent and prolonged the more invasive the treatment, hence most extensive in the group receiving open reduction with internal fixation (ORIF), intermediate in the group receiving closed reduction with percutaneous pinning (CRIF), and least extensive in the group undergoing closed reduction without internal fixation (CR). Besides time passed, gender and age were of significant influence on strength, although there was no difference in pattern of recovery over time between children who received a different treatment. In the period of 6 weeks to 3 months after trauma, female gender, type of fracture sustained and occurrence of an unwanted event were associated with an increased ratio between affected and expected grip strength. For the later phase of recovery, between 3 and 6 months, this was only true for the occurrence of an unwanted event.

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Implementation of the Amsterdam Pediatric Wrist Rules.

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Implementation of the Amsterdam Pediatric Wrist Rules.

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