A comparative analysis of the accuracy, diagnostic uncertainty and cost of imaging modalities in suspected scaphoid fractures

Jenkins, Paul J.; Slade, Kate; Huntley, James S; Robinson, C. M.

doi:10.1016/j.injury.2008.01.003

Cited by 83 publications

(104 citation statements)

References 40 publications

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“…Positive findings from MRI or CT provide strong evidence for the presence of a scaphoid fracture; however, positive findings from bone scintigraphy are insufficient to confirm fracture. The prevalence of true scaphoid fracture we presented was greater than that used by some investigators to calculate the posttest probability [1,42], but similar to the result of a recent epidemiologic study [29], in which the prevalence of true scaphoid fracture in patients with suspected scaphoid fracture was 16%. The prevalence of abnormality in a study sample rarely can be generalized beyond the study except when the study is based on a suitable random sample [15].…”

Section: Discussionsupporting

confidence: 85%

Diagnosing Suspected Scaphoid Fractures: A Systematic Review and Meta-analysis

Yin

Zhang

Kan

et al. 2010

Clinical Orthopaedics &Amp; Related Research

137

152

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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.

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Section: Discussionsupporting

confidence: 85%

Diagnosing Suspected Scaphoid Fractures: A Systematic Review and Meta-analysis

Yin

Zhang

Kan

et al. 2010

Clinical Orthopaedics &Amp; Related Research

137

152

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“…The prevalence of acute scaphoid fractures has averaged 7% among patients with acute wrist injuries 4,6,7 . In prospective studies of patients with clinical findings of an acute scaphoid fracture but negative findings on radiographs-identical to our study population-the reported prevalence in meta-analyses has averaged 16% 8,9 . This suggests that, on the average, only one of six patients who present to the emergency room with scaphoid A commentary by Scott Mitchell, MD, is available at www.jbjs.org/commentary and is linked to the online version of this article.…”

supporting

confidence: 69%

“…tenderness and normal findings on radiographs actually has a scaphoid fracture 9 and approximately 84% of patients may have unnecessary cast immobilization, resulting in a substantial loss of productivity 10,11 . In 2006, Groves et al performed a worldwide survey and found substantial variation in imaging and treatment protocols for acute scaphoid injuries 12 .…”

mentioning

confidence: 99%

“…It has been recommended that MRI is the best radiographic test for the diagnosis of suspected scaphoid fractures 12 , but bone scans, CT, and ultrasound may also be useful, particularly when MRI is not readily available 4 . CT and MRI have both been studied for their usefulness in establishing the diagnosis of scaphoid fractures 4,9 . MRI has been reported in case series as having a high sensitivity (98% to 100%) and specificity (100%) 5,[15][16][17][18][19][20] .…”

mentioning

confidence: 99%

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Comparison of CT and MRI for Diagnosis of Suspected Scaphoid Fractures

Mallee

Doornberg

Ring

et al. 2011

Journal of Bone and Joint Surgery

103

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“…Cost-effectiveness analyses performed regarding scaphoid fracture diagnosis thus far have not used diagnostic performance characteristics derived from metaanalyses, and none contemplate the role of ED pretest probability, physical examination accuracy, or testtreatment thresholds. [126][127][128][129][130] The current diagnostic meta-analysis provides summary estimates of diagnostic accuracy for advanced imaging in conjunction with an assessment of the role of the physical examination in the ED evaluation of patients with suspected scaphoid fractures. These estimates can be used to evaluate the comparative cost-effectiveness for various diagnostic strategies.…”

Section: Discussionmentioning

confidence: 99%

Adult Scaphoid Fracture

Carpenter

Pines

Schuur

et al. 2014

Academic Emergency Medicine

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ObjectivesScaphoid fractures are the most common carpal fracture, representing 70% of carpal bone fractures. The diagnostic accuracy of physical examination findings and emergency medicine (EM) imaging studies for scaphoid fracture has not been previously described in the EM literature. Plain x‐rays are insufficient to rule out scaphoid fractures in a patient with a suggestive mechanism and radial‐sided tenderness on physical examination. This study was a meta‐analysis of historical features, physical examination findings, and imaging studies for scaphoid fractures not visualized on plain x‐ray in adult emergency department (ED) patients, specifically to address which types of imaging tests should be recommended in patients with persistent concern for acute fracture after ED discharge.MethodsA medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED and EMBASE. The original studies' bibliographies were reviewed for additional references and unpublished manuscripts were located via a hand search of EM research abstracts from national meetings. All abstracts were independently reviewed by the two physicians, and Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS‐2) was used to assess individual study quality. When two or more qualitatively similar studies were identified, meta‐analysis was conducted using Meta‐DiSc software. Primary outcomes were sensitivity, specificity, and likelihood ratios (LRs) for predictors of scaphoid fracture detected on follow‐up in patients with normal ED x‐rays.ResultsA total of 957 unique citations were identified, yielding 75 studies eligible for inclusion in this systematic review. Studies were significantly heterogeneous in design, study population, and criterion standard. The majority of studies were conducted in non‐ED settings (e.g., orthopedic clinics). No studies used accepted diagnostic research publishing guidelines, and the overall QUADAS‐2 methodologic quality was low, indicating an increased risk of bias in the estimates of diagnostic accuracy. The prevalence of scaphoid fractures ranged from 12% to 57% with the point estimate of 25% pretest probability for adult ED patients with concern for scaphoid injuries, nondiagnostic index x‐rays, and scaphoid fractures on later imaging studies. Except for the absence of snuffbox tenderness (LR– = 0.15), physical examination findings lack accuracy to rule in or rule out scaphoid fractures, and no validated clinical decision rules exist. In patients with persistent concern for injury, magnetic resonance imaging (MRI) is superior to bone scan, computed tomography (CT), or ultrasound (US) to both rule in and rule out scaphoid fractures. Both MRI and CT share the added benefit of identifying alternative etiologies for posttraumatic wrist pain.ConclusionsExcept for the absence of snuffbox tenderness, which can significantly reduce the probability of scaphoid fracture, history and physical examination alone are inadequate to rule in or rule out scaphoid fracture. MRI is the most accurate imaging test to diagnose scaphoid fractures in ED patients with no evidence of fracture on initial x‐rays. If MRI is unavailable, CT is adequate to rule in scaphoid fractures, but inadequate for ruling out scaphoid fractures.

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A comparative analysis of the accuracy, diagnostic uncertainty and cost of imaging modalities in suspected scaphoid fractures

Cited by 83 publications

References 40 publications

Diagnosing Suspected Scaphoid Fractures: A Systematic Review and Meta-analysis

Diagnosing Suspected Scaphoid Fractures: A Systematic Review and Meta-analysis

Comparison of CT and MRI for Diagnosis of Suspected Scaphoid Fractures

Adult Scaphoid Fracture

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