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

Abstract

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.

Treatment of Acute Scaphoid Fractures: A Systematic Review and Meta-Analysis

“…Our findings are consistent with another recently published systematic review and meta-analysis [62]. The authors utilized stricter inclusion criteria to examine only randomized and quasi-randomized trials.…”

Surgical Compared with Conservative Treatment for Acute Nondisplaced or Minimally Displaced Scaphoid Fractures

“…Bhandari and Hanson 17 and Yin et al 16 previously performed meta-analyses on this subject. Both of those metaanalyses indicated that there was no evidence from randomized trials to determine whether surgical treatment was superior to conservative treatment.…”

“…Two previous meta-analyses on the treatment of acute scaphoid fractures indicated that current evidence failed to prove the superiority of operative as compared with conservative treatment 16,17 . However, since the publication of those reviews, additional data have been published, and the discussion about the indications for operative treatment is ongoing 13,18 .…”

Adult Scaphoid Fracture

“…24 Two diagnostic meta-analyses have been published in the orthopedic surgery literature to evaluate advanced imaging modalities for scaphoid fracture, but none focus on history and physical examination diagnostic accuracy or ED-specific pretest probability, all necessary to facilitate Bayesian reasoning for bedside clinicians. 25,26 One consequence of the lack of a synopsis of all of these diagnostic estimates is interphysician inconsistency in selection and timing of more definitive imaging and post-ED management decisions. 27,28 The primary objective of this meta-analysis was to assess the pretest probability and pooled diagnostic test characteristics (sensitivity, specificity, and likelihood ratios [LRs]) for occult scaphoid fracture considering all relevant elements of the history and physical examination, as well as imaging tests that are available in the ED.…”