After acute wrist trauma about half of emergency patients have a fracture, and even a validated decision rule (98% sensitive, 21% specific) spares only one X-ray in ten
A fall onto the hand with swelling or bone tenderness is imaged
Key Findings
In the external validation cohort the Amsterdam Wrist Rules had a sensitivity of 98% (95% CI 95–99) and a specificity of 21% (15–28); the negative predictive value was 90%.
A fracture of the distal radius, distal ulna or a carpal bone was found in 470 of 882 adults (53%) seen for acute wrist trauma in five hospitals.
Predictors in the rule: sex, age, visible deformation, wrist swelling, anatomical snuffbox swelling, tenderness of the distal radius on palpation, painful axial compression of the thumb, and pain on radial deviation.
Using the rule would have saved 10% of X-rays at the cost of 4 missed fractures (1.6%), two of them scaphoid.
Practical Application
After a fall onto the hand, these mean a clinician and an X-ray the same day: visible deformity, swelling of the wrist, tenderness over the end of the forearm bone on the thumb side, pain when the wrist is bent toward the thumb side, or pain when the thumb is pushed along its own axis.
Never tell an athlete "it is not broken" because a sign is absent: half of such injuries are fractures, and the rule's own specificity is 21%.
No pressing, hanging or handlebar load on that hand, and no decision about training on it, until it has been examined.
Limitations
The reference standard was plain X-ray, so occult carpal fractures are undercounted; the authors advise caution before the rule's real-world effect is evaluated. Full text was read.