Imaging protocols for suspected scaphoid fractures among investigators and hospitals are markedly inconsistent. We performed a systematic review and metaanalysis to assess and compare the diagnostic performance of bone scintigraphy, MRI, and CT for diagnosing suspected scaphoid fractures. Twenty-six studies were included. Sensitivity, specificity, and diagnostic odds ratio were pooled separately and summary receiver operating characteristic curves were fitted for each modality. Metaregression analyses were performed to compare these modalities. We obtained likelihood ratios derived from the pooled sensitivity and specificity and, using Bayes' theorem, calculated the posttest probability by application of the tests. The pooled sensitivity, specificity, natural logarithm of the diagnostic odds ratio, and the positive and negative likelihood ratios were, respectively, 97%, 89%, 4.78, 8.82, and 0.03 for bone scintigraphy; 96%, 99%, 6.60, 96, and 0.04 for MRI; and 93%, 99%, 6.11, 93, and 0.07 for CT. Bone scintigraphy and MRI have equally high sensitivity and high diagnostic value for excluding scaphoid fracture; however, MRI is more specific and better for confirming scaphoid fracture. We believe additional studies are needed to assess diagnostic performance of CT, especially paired design studies or randomized controlled trials to compare CT with MRI or bone scintigraphy.

Economic and Decision Analyses Level II. See Instructions for Authors for a complete description of levels of evidence.

Whether operative treatment is a better option than nonoperative treatment for acute nondisplaced or minimally displaced fractures of the scaphoid is controversial. The type of cast that should be used for nonoperative treatment is not known. We performed a systematic review and meta-analysis of randomized and quasirandomized trials to evaluate the effect of operative versus nonoperative treatment and the effect of different casting methods for nonoperative treatment of acute scaphoid fractures on nonunion rate, return to work, grip strength, range of wrist motion, complications, patient evaluation, and incidence of osteoarthritis. Two investigators assessed trial quality and extracted data. Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization; however, it causes more complications and, perhaps, a higher risk of scaphotrapezial osteoarthritis. There is no evidence from randomized trials to determine whether operative treatment is superior to nonoperative treatment for an acute proximal pole fracture of scaphoid bones. There is insufficient evidence to determine which type of cast should be used in nonoperative treatment of nondisplaced scaphoid fractures.