Amsterdam wrist rules

The Amsterdam wrist rules are validated clinical decision rules for determining which patients require radiographic imaging (wrist radiography) for acute wrist pain following trauma. The initial study evaluated 882 patients and were published in 2015 . The decision rules assessed different clinical parameters that increase the likelihood of either a distal radial fracture or any wrist fracture, but did not recommend a threshold value for imaging or not.

By applying the rule, the study showed an absolute reduction of 10% in the number of radiographs performed, but at a cost of 4 missed fractures (none of which had increased morbidity).

For distal radial fractures, the following parameters increase the likelihood of a fracture (with a sensitivity of 98%):

• increased age
• swelling of the wrist
• visible deformation
• distal radius tender to palpation
• pain on palmar flexion
• pain on supination
• painful radioulnar ballottement test

Pain on ulnar deviation was found to decrease the likelihood of a distal radial fracture.

For any wrist fracture, the following parameters increases the likelihood of a fracture (with a sensitivity of 98% and negative predictive value of 90%):

• increased age
• male sex
• swelling of the wrist
• swelling of the anatomical snuffbox
• visible deformation
• distal radius tender to palpation
• pain on radial deviation

Painful axial compression of the thumb was found to decrease the likelihood of any wrist fracture.

As with all clinical decision rules, the study supports the use of the rules which aims at selecting appropriate patients for investigation as to avoid unnecessary radiography, thereby decreasing patient radiation exposure. There are also potential departmental benefits expected to be confirmed with further research including reducing emergency department waiting times and decreasing financial costs.