You are here

Article Text

Article menu
Download PDFPDF
Original research
Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies
  1. Laura Coventry1,
  2. Ilaria Oldrini1,
  3. Ben Dean2,
  4. Alex Novak3,
  5. Andrew Duckworth4,5,
  6. David Metcalfe1,2,3
  1. 1 Warwick Medical School, University of Warwick, Coventry, UK
  2. 2 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  3. 3 Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  4. 4 Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
  5. 5 Centre for Population Health Sciences, Usher Institute,University of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr David Metcalfe, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; david.metcalfe{at}ndorms.ox.ac.uk

ABSTRACT

Background Plain radiographs cannot identify all scaphoid fractures; thus ED patients with a clinical suspicion of scaphoid injury often undergo immobilisation despite normal imaging. This study determined (1) the prevalence of scaphoid fracture among patients with a clinical suspicion of scaphoid injury with normal radiographs and (2) whether clinical features can identify patients that do not require immobilisation and further imaging.

Methods This systematic review of diagnostic test accuracy studies included all study designs that evaluated predictors of scaphoid fracture among patients with normal initial radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analyses included all studies.

Results Eight studies reported data on 1685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 9.0%. Most studies were at overall low risk of bias but two were at unclear risk; all eight were at low risk for applicability concerns. The most accurate clinical predictors of occult scaphoid fracture were pain when the examiner moved the wrist from a pronated to a supinated position against resistance (sensitivity 100%, specificity 97.9%, LR+ 45.0, 95% CI 6.5 to 312.5), supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR+ 3.7, 95% CI 2.2 to 6.1), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR+ 2.3, 95% CI 1.8 to 3.0) and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR+ 2.0, 95% CI 1.2 to 3.2). Absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1%, specificity 48.4%, LR- 0.2, 95% CI 0.0 to 0.7).

Conclusion No single feature satisfactorily excludes an occult scaphoid fracture. Further work should explore whether a combination of clinical features, possibly in conjunction with injury characteristics (such as mechanism) and a normal initial radiograph might exclude fracture. Pain on supination against resistance would benefit from external validation.

Trial registration number CRD42021290224.

  • fractures
  • Diagnostic Tests
  • hand injuries

Data availability statement

Data are available upon reasonable request. The underlying study data are available on request to the corresponding author.

https://doi.org/10.1136/emermed-2023-213119

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Data availability statement

    Data are available upon reasonable request. The underlying study data are available on request to the corresponding author.

    View Full Text

    Footnotes

    • Handling editor Ceri Battle

    • Twitter @i_oldrini, @AlexTNovak, @DuckworthOrthEd, @TraumaDataDoc

    • Presented at An earlier iteration of the data presented in the results section was published at the 2022 RCEM Annual Scientific Meeting. Full details are listed in reference 31.

    • Contributors LC led the review process (including abstract screening, data extraction and quality assessments) with IO and supervised by DM. LC and DM drafted the manuscript. IO, BD, AN and AD contributed to the study design, helped interpret the data, and made critical revisions to the manuscript. DM is guarantor.

    • Funding DM is supported by an NIHR Advanced Fellowship and the NIHR Oxford Biomedical Research Centre but neither organisation was directly involved with this study.

    • Competing interests DM and AN are members of the EMJ editorial board.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.