Early Computed Tomography Compared With Bone Scintigraphy in Suspected Scaphoid Fractures

Rhemrev, Steven J.; Zwart, Andele D. de; Kingma, L M; Meylaerts, S.A.G.; Arndt, J. W.; Schipper, Inger B.; Beeres, Frank J. P.

doi:10.1097/rlu.0b013e3181f9de26

Cited by 29 publications

(30 citation statements)

References 28 publications

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“…[36][37][38][39][40] Among more recent, prospective ED-based studies that used MRI or bone scan as criterion standards, the prevalence of scaphoid fractures in patients with appropriate clinical suspicion and nondiagnostic initial x-rays ranges from 17% to 38%. [37][38][39][40] Therefore, based on these four prospective, ED-based diagnostic studies including a total of 274 patients, we think a reasonable pretest probability for adult ED patients with persistent wrist pain suspicious for a scaphoid fracture while still in the ED and normal ED x-rays is 25%. In other words, one in four of these patients will have a scaphoid fracture diagnosed on subsequent imaging.…”

Section: Prevalencementioning

confidence: 99%

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 The original studies' bibliographies were reviewed for additional references and unpublished manuscripts were located via a hand search of EM research abstracts from national meetings.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

confidence: 99%

“…38,40,56,[65][66][67][68][69][70][71][72][73][74][75][76][77][78][79] All of the pre-1995 studies used an x-ray/clinical examination composite as the criterion standard, although the timing of this follow-up evaluation ranged from 14 days to 1 year. After 1995, several studies also included MRI as an acceptable criterion standard.…”

Section: Bone Scanmentioning

confidence: 99%

Adult Scaphoid Fracture

Carpenter

Pines

Schuur

et al. 2014

Academic Emergency Medicine

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“…If, however, there is no dislocation of the compact and spongy bone, the fracture cannot be detected, even using CT [16]. In the rare case that MRI is used to detect or exclude fracture, its sensitivity is 100 % ("no fracture missed"), but its specificity -80 to 90 % -is lower than CT [17].…”

Section: Resultsmentioning

confidence: 98%

“…The utilization of three-phase scintigraphy is supported by the high negative predictive value after the third day post-injury, the high positive predictive value in the case of patients with an initial negative X-ray finding and simultaneous evidence of injury to the remaining bones of the hand [13,17,22]. Due to its poor spatial resolution and low specificity, positive findings in scintigraphy must always be supplemented by a subsequent CT and/or MRI diagnosis.…”

Section: Bone Scintigraphymentioning

confidence: 99%

Imaging of Scaphoid Fractures According to the New S3 Guidelines

Schmitt

Rosenthal

Unfallchirurgie³

2016

Fortschr Röntgenstr

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▼Up to 30 % of acute scaphoid fractures are missed in conventional radiography. CT and MRI should be early performed in the diagnostic workflow, when radiograms (dorsopalmar, lateral and Stecher's views) are negative or inconclusive in fracture detection. Significance of CT is different from that of MRI: Sensitivity of CT imaging (85 to 95 %) is superior to conventional radiography (about 70 %), but inferior to MRI (almost 100 %). However, CT (specificity 95 to 100 %) is able to provide more detailed anatomic information of the fracture pattern when compared to MRI (specificity 80 to 90 %). Particularly, differentiation of bone contusion ("bone bruise") and non-displaced fracture can be difficult in MRI. Thus, CT indication is not only given for fracture detection, but also for assessing the morphology in scaphoid fractures (localization, fragment dislocation, comminuted zones) and the fragment instability, too. MRI should be limited to equivocal trauma cases presenting pain in the snuff box, but with inconclusive CT findings. In CT and MRI of scaphoid fractures, image display must be aligned along the longitudinal extension of the scaphoid, either by acquiring or reformatting oblique-sagittal and obliquecoronal planes. Key points ▶ Radiography can be limited to the dorsopalmar, lateral and Stecher's views in scaphoid fractures.▶ In CT and MR imaging, the dedicated anatomy of the scaphoid has to be covered with oblique-sagittal and oblique-coronal images.

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“…Scaphoid fractures are reported to represent 2% -7% of all fractures and over 70% of all hand fractures presenting to accident and emergency departments [1]. Seventy percent of all scaphoid fractures are through the waist of the bone.…”

Section: Introductionmentioning

confidence: 99%

Functional outcome in conservatively treated non-displaced scaphoid fractures

Drijkoningen¹,

Beeres²,

Leerdam³

et al. 2012

OJCD

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Purpose: This study evaluated the functional outcome after conservative treatment of non-displaced scaphoid fractures using an international validated outcome scale (DASH). Methods and materials: Between 2005 and 2010, 60 patients with a non-displaced scaphoid fracture were included. When a patient visited the emergency department and was clinically suspected of a scaphoid fracture radiography was performed. If no fracture was diagnosed with this modality a CT or MRI-scan both in combination with bonescintigraphy was performed. Patients with scaphoid fractures diagnosed with CT/MRI and bonescintigraphy were treated with a six-week scaphoid forearm cast. Within 1 year after cast removal patients filled in the DASH questionnaire. Results: Sixty (80%) patients returned the DASH questionnaire at 12 months after treatment. Thirty-eight (63.3%) were male and the mean age was 35 (range 11 -83). Forty-four (73.3%) patients had a mid-waist fracture of the scaphoid, 13 (21.7%) had a fracture of the distal pole and three (0.05%) had a proximal fracture. Median DASH score at one year after the trauma was 6 (range 3 -15) for patients with a distal pole fracture and 5 (range 0 -21.5) for mid-waist fractures (p = 0.7, Table 2). For the three patients with a proximal scaphoid fracture the DASH scores appeared higher and were 83, 82 and 30 respectively. Conclusion: Conservative treatment for six weeks with a below the elbow cast is sufficient for the majority of patients with an occult distal or mid-waist scaphoid fracture and results in a good functional outcome according to the DASH questionnaire.

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Early Computed Tomography Compared With Bone Scintigraphy in Suspected Scaphoid Fractures

Abstract: This study could not confirm that early CT imaging is superior to bone scintigraphy for suspected scaphoid fractures.

Cited by 29 publications

References 28 publications

Adult Scaphoid Fracture

Adult Scaphoid Fracture

Imaging of Scaphoid Fractures According to the New S3 Guidelines

Functional outcome in conservatively treated non-displaced scaphoid fractures

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