Clinical prediction rule for suspected scaphoid fractures

Rhemrev, Steven J.; Beeres, Frank J. P.; Leerdam, Roderick H. van; Hogervorst, Mike; Ring, David

doi:10.1016/j.injury.2010.03.029

Cited by 40 publications

(39 citation statements)

References 16 publications

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“…Two studies derived clinical decision rules for scaphoid fractures, but neither has been subsequently validated. 47,48 As demonstrated in the forest plots (Figures 3-9 resisted supination (LR-= 0.09, 95% CI = 0.00 to 11.9, I 2 = 91%), which significantly reduce the probability of a scaphoid fracture. No other physical examination finding has a LR-less than 0.22, including the poorly defined "clinical examination."…”

Section: History and Physical Examinationmentioning

confidence: 84%

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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 The original studies' bibliographies were reviewed for additional references and unpublished manuscripts were located via a hand search of EM research abstracts from national meetings.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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Section: History and Physical Examinationmentioning

confidence: 84%

“…Although two scaphoid clinical decision rules have been derived, neither has been validated. 47,48 Future studies that seek to validate these rules need to adhere to accepted research designs. 123 One "diagnostic test" that future ED clinical decision rules should evaluate is "physician gestalt" for scaphoid fracture.…”

Section: Discussionmentioning

confidence: 99%

Adult Scaphoid Fracture

Carpenter

Pines

Schuur

et al. 2014

Academic Emergency Medicine

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“…The second cohort (MRI versus bone scintigraphy and clinical tests) included 78 patients who visited one emergency department for a suspected scaphoid fracture between April 2004 and January 2007 [28]. We included adult patients with a suspected scaphoid fracture (tender anatomic snuffbox and pain in the snuffbox when applying axial pressure on the first or second digit), recent trauma (within 48 hours), and no evidence of a fracture on scaphoid-specific radiographs.…”

Section: Methodsmentioning

confidence: 99%

Diagnostic Performance Tests for Suspected Scaphoid Fractures Differ with Conventional and Latent Class Analysis

Buijze

Mallee

Beeres

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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“…Therefore, clinical predictions rules are being investigated to yield a subset of patients who are more likely to have a fracture than others who laced the criteria. An initial study [28] regarding scaphoid fractures has been performed on this issue. However, we should broaden our view and see if we can make a clinical prediction rule for the hand and wrist.…”

Section: Discussionmentioning

confidence: 99%

Occult Fractures in the Carpal Region: Incidental Findings on Bone Scintigraphy

Zoakman¹,

Leerdam²,

Beeres³

et al. 2013

OJO

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The aim of this study was to evaluate the number and distribution of fractures around the wrist found on bone scintigraphy in patients with a clinically suspected scaphoid fracture and negative initial radiographs. We retrospectively included 445 consecutive patients with a suspected scaphoid fracture who underwent routine bone scintigraphy. None of the radiographs showed evidence of a fracture. We analyzed the type and number of other fractures incidentally found on bone scintigraphy. On average, bone scintigraphy was done in 4 days (1 -9). The outcome of bone scintigraphy: 80 (18.0%) a scaphoid fracture, 145 (32.6%) another fracture in the carpal region, 208 (46.7%) normal and the diagnosis of 12 (2.8%) was unclear. In the present study, we demonstrated that in patients with a clinically suspected scaphoid fracture and negative initial radiographs, bone scintigraphy detected in many cases (64.4%) other fractures in the carpal region. This suggests that radiographs not only miss scaphoid but also many other carpal and distal radius fractures. Solutions should be found to solve this problem and probably advanced imaging techniques like CT, MRI or bone scintigraphy should be used in the correct clinical scenario.

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Clinical prediction rule for suspected scaphoid fractures

Cited by 40 publications

References 16 publications

Adult Scaphoid Fracture

Adult Scaphoid Fracture

Diagnostic Performance Tests for Suspected Scaphoid Fractures Differ with Conventional and Latent Class Analysis

Occult Fractures in the Carpal Region: Incidental Findings on Bone Scintigraphy

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