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Diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures: a systematic review update

BMC Musculoskeletal Disorders volume 21, Article number: 12 (2020) Cite this article

Abstract

Background

The standard diagnostic work-up for hand and wrist fractures consists of history taking, physical examination and imaging if needed, but the supporting evidence for this work-up is limited. The purpose of this study was to systematically examine the diagnostic accuracy of tests for hand and wrist fractures.

Methods

A systematic search for relevant studies was performed. Methodological quality was assessed and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted from the eligible studies.

Results

Of the 35 eligible studies, two described the diagnostic accuracy of history taking for hand and wrist fractures. Physical examination with or without radiological examination for diagnosing scaphoid fractures (five studies) showed Se, Sp, accuracy, PPV and NPV ranging from 15 to 100%, 13–98%, 55–73%, 14–73% and 75–100%, respectively. Physical examination with radiological examination for diagnosing other carpal bone fractures (one study) showed a Se of 100%, with the exception of the triquetrum (75%). Physical examination for diagnosing phalangeal and metacarpal fractures (one study) showed Se, Sp, accuracy, PPV and NPV ranging from 26 to 55%, 13–89%, 45–76%, 41–77% and 63–75%, respectively.

Imaging modalities of scaphoid fractures showed predominantly low values for PPV and the highest values for Sp and NPV (24 studies). Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Ultrasonography (US) and Bone Scintigraphy (BS) were comparable in diagnostic accuracy for diagnosing a scaphoid fracture, with an accuracy ranging from 85 to 100%, 79–100%, 49–100% and 86–97%, respectively. Imaging for metacarpal and finger fractures showed Se, Sp, accuracy, PPV and NPV ranging from 73 to 100%, 78–100%, 70–100%, 79–100% and 70–100%, respectively.

Conclusions

Only two studies were found on the diagnostic accuracy of history taking for hand and wrist fractures in the current review. Physical examination was of moderate use for diagnosing a scaphoid fracture and of limited use for diagnosing phalangeal, metacarpal and remaining carpal fractures. MRI, CT and BS were found to be moderately accurate for the definitive diagnosis of clinically suspected carpal fractures.

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Background

Hand and wrist injuries are among the most common traumatic presentations to the emergency department [1, 2], and commonly affect young people of working age [3, 4]. Scaphoid fractures are the most frequently injured carpal bones, accounting for 61–90% of fractures [4,5,6]. The diagnosis of a scaphoid fracture may however be difficult to establish on a conventional radiograph [7, 8]. Previous research has shown that 10–35% of scaphoid fractures are missed on primary radiographs [4, 9,10,11,12]. Metacarpal fractures are detected in 30–40% of all hand fractures in all emergency department admissions [4, 9, 10].

Hand and wrist injuries represent a considerable economic burden, with high health-care and productivity costs [13]. The total costs have been estimated at US $410 million per year, with US $307 million in productivity costs [14].

If not treated properly, patients with hand and wrist injuries may experience lifelong pain and lose their job, which also has major effects on their quality of life [15]. Accurate diagnosis and early treatment of hand and wrist fractures are important because missed diagnosis and delayed initiation of therapy increase the risk of complications and subsequent functional impairment [16,17,18,19,20,21,22].

In recent decades, research has predominantly focused on imaging modalities for the diagnosis of wrist fractures. However, the standard diagnostic work-up for wrist complaints that are suspected fractures should also include detailed patient history taking, a conscientious physical examination and, only if needed, imaging [23]. It has been shown that different provocative tests are somewhat useful for diagnosing wrist fractures [24,25,26,27], but there is no consensus on imaging protocols due to limited evidence regarding the diagnostic performance of these advanced imaging techniques [28]. Therefore, diagnosing wrist pathologies remain complex and challenging and there is increasing demand for evidence for accurate diagnostic tools [29].

Diagnostic studies performed in hospital care cannot automatically be translated into guidelines for non-institutionalized general practitioner care [30]. The clinical utility of diagnostic tests for hand and wrist fractures is hindered by the low prevalence of true fractures, approximately 7% on average [31].

Currently, there are several systematic reviews available on the diagnostic accuracy of tests for the diagnosis of hand and wrist fractures, as presented in Table 1 [32,33,34,35,36,37,38,39]. Of these, only the review by Carpenter et al. used ‘history’ as a keyword in their search terms, but they could not find studies assessing the diagnostic accuracy of history for scaphoid fractures [32]. All the available systematic reviews only examined diagnostic tests for scaphoid fractures [32,33,34,35,36,37,38,39], while in practice it is often not quite clear during the diagnostic process which hand or wrist anatomical structure or tissue (soft tissue or bone) is affected. Moreover, these reviews focused predominantly on imaging as a diagnostic tool, while in clinical practice a diagnosis is mainly made on history taking and physical examination.

Table 1 Characteristics of the Currently Available Systematic Reviews on the Diagnostic Accuracy of Tests
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Therefore, the purpose of this literature review is to provide an up-to-date systematic overview of the diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures and to distinguishing between studies in hospital and non-institutionalized general practitioner care settings, as test properties may differ between settings. Compared to previously published reviews, in this systematic review we also included studies that examined history taking and physical examination for phalangeal, metacarpal or carpal fractures.

Methods

Data sources and searches

A review protocol was drafted, but central registration was not completed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was used to guide the conduct and reporting of the study [40]. A Biomedical Information specialist (Wichor M. Bramer) performed a search for studies in Medline, Embase, Cochrane Library, Web of Science, Google Scholar ProQuest and Cinahl from 2000 up to 6 February 2019. This starting point was used since multiple reviews are available that already cover the period up to the year 2000 (Table 1). Search terms included phalangeal, metacarpal and carpal injuries, anamnestic assessment, provocative test(s), diagnostic test(s) and imaging tests. The full electronic search strategy for the Embase database is presented in Table 2 (the others are available upon request).

Table 2 Example electronic search strategy
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Study selection

Studies describing diagnostic accuracy of history taking, physical examination or imaging in adult patients (age ≥ 16 years) with phalangeal, metacarpal and/or carpal fractures were included. No language restriction was applied. Case reports, reviews and conference proceedings were excluded. Distal radius and ulna injuries were also excluded, as they can be diagnosed accurately with plane X-ray or computer tomography imaging.

Two reviewers (PK, YA) read all titles and abstracts independently. Articles that could not be excluded on the basis of the title and/or abstract were retrieved in full text and were read and checked for inclusion by the two reviewers independently. If there was no agreement, a third reviewer (JR) made the final decision. In addition, the reference lists of all included studies were reviewed to check for additional relevant studies.

Data extraction and methodological quality assessment

Two reviewers (PK, JR) independently extracted the data. Data were extracted describing the study design, characteristics of the study population, test characteristics, study population setting (hospital care or non-institutionalized general practitioner care) and diagnostic parameters. Methodological quality was assessed by two independent reviewers (PK, JR), using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist [41]. Disagreements were resolved by discussion.

Heterogeneity

Key factors in a meta-analysis are the number and the methodological quality of the included studies and the degree of heterogeneity in their estimates of diagnostic accuracy [42]. Heterogeneity in diagnostic test accuracy reviews is expected and the possibilities of performing meta-regression analyses will depend on the number of studies available for a specific index test that provide sufficient information [39]. The data from the included studies were combined when studies showed no limitations according to QUADAS-2 and had no other forms of bias (e.g. incorporation bias).

Data synthesis and analysis

The following values were extracted, if documented: sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratio (LR). If these diagnostic outcomes were not reported, they were calculated using published data. If an included study presented results from multiple independent observers, the measures of Se, Sp, accuracy, PPV and NPV were averaged over the observers.

Index test

Diagnostic tools such as history taking, physical examination or imaging were accepted as index tests.

Reference standard

There is no consensus about the reference test for the diagnosis of a true fracture of the phalangeal, metacarpal or carpal bones [35]. Therefore, in this systematic review clinical outcome (physical examination or additional treatment) and/or various (combined) imaging modalities during follow-up were used as the reference standard for confirming diagnosis of phalangeal, metacarpal or carpal fractures.

Results

The flow diagram is presented in Fig. 1. A total of 35 diagnostic studies were identified, assessed and interpreted. The characteristics of these studies are presented in Table 3. 20 studies were performed in an emergency department, four studies in a traumatology setting and three other studies in a radiology department. The patients in the studies by Mallee et al. [56,57,58] were derived from one prospective study; therefore the setting was the same for each study: patients were initially seen by the emergency physicians and in follow-up by the orthopaedic department and/or trauma surgery department, depending on who was on call. In five studies the setting was not specified. To our knowledge, all first authors of those five studies were working in a hospital care setting, so we assume all to have been done in hospital care. History taking, physical examination and imaging as index tests were investigated in 0, 20% (7/35) [48, 53, 62, 64, 67, 73, 77] and 86% (30/35) [43,44,45,46,47, 49,50,51, 53,54,55,56,57,58,59,60,61, 63, 65, 66, 68,69,70,71,72,73,74,75,76,77] of the studies, respectively.

Fig. 1
figure 1

Flow chart study selection

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Table 3 Characteristics of the Eligible Studies (N = 35)
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Quality assessment

There was considerable underreporting of important quality domains in 23 of the 35 studies (see Table 4). In 13 of the 35 studies [43, 44, 48, 50, 54, 55, 59, 64, 67, 72, 74, 76, 77], patient selection was not well documented. Furthermore, the risk of bias was predominantly due to the absence of a proper description of the index test (9/35) [43, 45, 49, 53, 55, 64, 65, 72, 77] or the reference standard (13/35) [45, 49, 55, 62, 64,65,66,67,68, 71,72,73, 75]. Twelve of the studies (34%) demonstrated no limitations when risk of bias was assessed, according to QUADAS-2 [46, 47, 51, 52, 56,57,58, 60, 61, 63, 69, 70]. Eight showed incorporation bias [46, 47, 49, 55, 60, 62, 66, 69].

Table 4 Summary of Methodological Quality according to Quality Assessment of Diagnostic Accuracy Studies-2
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Diagnosing carpal fractures in hospital care

Table 5 presents the accuracy of the diagnostic tests of all the carpal fractures. Two studies described the diagnostic accuracy of history taking [62, 67]. Physical examination [48, 53, 62, 64] and combined physical and radiological examination [52] for diagnosing scaphoid fractures showed Se, Sp, accuracy, PPV and NPV ranging from 15 to 100%, 13–98%, 55–73%, 14–73% and 75–100%, respectively.

Table 5 Diagnostic Accuracy of the Diagnostic Tests of the Carpal, Metacarpal and Phalangeal Fractures (N=35)
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Repeated physical examination with radiological examination after 38 days [52] for diagnosing other carpal bone fractures showed a Se of 100% with the exception of the triquetrum (75%).

Radiographs used as an index test for diagnosing scaphoid fractures showed Se, Sp, accuracy, PPV and NPV ranging from 25 to 87%, 50–100%, 48–88%, 14–100% and 49–94%, respectively. For diagnosing scaphoid fractures, Magnetic Resonance Imaging (MRI) as an imaging modality showed Se, Sp, accuracy, PPV and NPV ranging from 67 to 100%, 89–100%, 85–100%, 54–100% and 93–100%, respectively. Multi Detector Computed Tomography (MDCT) showed Se, Sp, accuracy, PPV and NPV ranging from 33 to 100%, 85–100%, 79–100%, 28–100% and 86–100%, respectively. Bone Scintigraphy (BS) as an index test for diagnosing scaphoid fractures showed Se, Sp, accuracy, PPV and NPV ranging from 78 to 100%, 87–97%, 86–97%, 62–78% and 90–100%, respectively. For diagnosing scaphoid fractures, Ultrasonography (US) as an imaging modality showed Se, Sp, accuracy, PPV and NPV ranging from 78 to 100%, 34–100%, 49–100%, 30–100% and 75–100%, respectively.

Diagnosing phalangeal and metacarpal fractures in hospital care

Table 5 also presents the accuracy of the diagnostic tests for metacarpal and/or phalangeal fractures, as described in six studies [71, 73,74,75,76,77]. Physical examination [77] for diagnosing phalangeal and metacarpal fractures showed Se, Sp, accuracy, PPV and NPV ranging from 26 to 55%, 13–89%, 45–76%, 41–77% and 63–75%, respectively. Imaging for metacarpal and finger fractures showed Se, Sp, accuracy, PPV and NPV ranging from 73 to 100%, 78–100%, 70–100%, 79–100% and 70–100%, respectively. The reported diagnostic accuracy measures of phalangeal and metacarpal fractures were characterized by markedly heterogeneous results among the eligible studies.

Combined diagnostic accuracy of the studies with no limitations and no incorporation Bias

Table 6 shows combined diagnostic accuracy measures of the studies that had no limitations and no incorporation bias. A wide range of results were found for the specificity, accuracy and NPV of MRI, US, CT and BS. The sensitivity of BS and US showed similar, acceptable results. US and MRI are imaging tools that have similar PPV, but with large confidence intervals.

Table 6 Combined Diagnostic Accuracy of the Studies with no Limitations on QUADAS-2 and No Incorporation Bias (N = 7)
Full size table

Discussion

In previous reviews, no studies were identified on the diagnostic accuracy of history taking for phalangeal, metacarpal or carpal fractures. In the current systematic review, only two such studies were identified. This update included one extra study on physical examinations for diagnosing scaphoid fractures in hospital care, which was not included in previous reviews [48]. Based on these results and those presented in the previous reviews, physical examination is of moderate use for diagnosing a scaphoid fracture. Physicians should be aware that tenderness in the anatomical snuff box (ASB), tenderness over the scaphoid tubercle and pain on longitudinal compression of the thumb have limited added value in a diagnostic process for a scaphoid fracture.

The present systematic review identified eight supplementary imaging studies [58, 61, 65, 66, 68,69,70, 74], subdivided into MRI [66], CT [58, 66, 68,69,70], BS [66] and US [61, 65, 74]. The overall conclusion is that imaging tests were found to be moderately accurate for a definitive diagnosis. However, the standard diagnostic work-up for wrist complaints suspected of being a fracture should also include detailed patient history taking, a conscientious physical examination and, only if needed, imaging [23]. Diagnostic studies focusing on history taking and physical examination of patients with suspected phalangeal, metacarpal and carpal fractures are therefore desired.

Compared with previous reviews, the current systematic review attempted to distinguish between studies based on their setting. Remarkably, no studies examined the diagnostic accuracy of any diagnostic test for phalangeal, metacarpal and carpal fractures in a non-institutionalized general practitioner care setting. It is known that results from hospital care cannot automatically be translated into guidelines for non-institutionalized general practitioner care. For that reason, it is not possible to advise general practitioners properly on the diagnosis of carpal, metacarpal and phalangeal fractures based on the currently available literature. Given the burden of finger, hand and wrist fractures on non-institutionalized care and the importance of proper diagnoses, diagnostic studies focusing on phalangeal, metacarpal and carpal fractures in non-institutionalized general practitioner care are urgently needed [2].

Methodological quality assessment

The methodological quality of the eligible studies included in this update was limited, which might affect the estimates of diagnostic accuracy. Many of the included studies had methodological flaws and lacked the necessary details to replicate the studies. There was considerable underreporting of important domains in most of the included studies. The studies in this and previous systematic reviews also had the inherent risk of publication bias. As the mechanisms of publication bias are not yet well understood for diagnostic accuracy studies, there are currently no assessment tools available to investigate this risk other than graphical interpretation. Furthermore, several studies demonstrate incorporation bias, with the risk of overestimation of the diagnostic accuracy [78].

Diagnostic accuracy of the diagnostic tests for phalangeal and metacarpal fractures

The identified studies evaluated a variety of metacarpal and phalangeal pathologies. US may be an option for detecting metacarpal fractures and prevent unnecessary X-ray imaging examinations in patients presenting to the Emergency Department (ED) with hand trauma. Some advantages of US have increased its utilization in emergency departments; these include a short procedure time, a non-invasive and nonionizing radiation involving nature, availability for use in nonhospital settings or bedside settings, repeatability, and a higher safety in children and pregnant patients [79].

None of the previous reviews included studies showing evidence on the diagnostic accuracy for diagnosing metacarpal and phalangeal fractures. Therefore, this is the first study to systematically summarize the diagnostic accuracy of diagnostic tests for phalangeal and metacarpal fractures. This study concludes that physical examination was of limited use for diagnosing phalangeal and metacarpal fractures.

Diagnostic accuracy of history taking and physical examination of carpal fractures

History taking and physical examination are important tools in a diagnostic process of diagnosing patients with wrist pain [23]. Although common practice in hospital care, only two studies were found on the diagnostic accuracy of history taking for carpal fractures in the previous reviews and current review.

Previous reviews reported that tenderness in the anatomical snuff box demonstrated an Se and Sp for scaphoid fractures ranging from 87 to 100% and 3–98%, respectively [32, 34]. Tenderness over the scaphoid tubercle (ST) demonstrated a Se and Sp ranging from 82 to 100% and 17–57%, respectively [32, 34]. The Longitudinal Thumb Compression test (LTC) demonstrated a Se and Sp ranging from 48 to 100% and 22–97%, respectively [32, 34].

The current systematic update included three extra studies on physical examinations for diagnosing scaphoid fractures in hospital care [48, 52, 53]. Based on these results and those presented in the previous reviews, combining provocative tests improved the accuracy of the post-test fracture probability, and physical examination alone was not sufficient to rule in or rule out scaphoid fracture, which may lead to unnecessary out-patient reviews and/or overtreatment. If a patient with wrist pain and normal X-rays has a combination of tenderness in the anatomical snuff box, tenderness over the scaphoid tubercle and longitudinal compression (LC) tenderness towards the scaphoid, supplementary imaging is still recommended. At present, in a patient with a strong suspicion of a scaphoid fracture based on history taking and physical examination despite no deviation on imaging, the wrist will be temporarily immobilized until repeated evaluation of the physical examination and imaging has taken place later [80].

Diagnostic accuracy of imaging of carpal fractures

In this and previous systematic reviews, the reported diagnostic accuracy measures for imaging modalities were characterized by markedly heterogeneous results among the eligible studies. Plain radiography remained the commonest modality for diagnosing carpal fractures [81,82,83]. Its advantages include its wide availability, easy accessibility and low costs. Most studies describe diagnostic tests of scaphoid fractures and only a few studies concern other carpal fractures. At present, there is still insufficient scientific evidence regarding the ideal imaging technique for scaphoid fractures [23]. Repeated radiographs seems to have limited value for evaluating suspected scaphoid fractures. The irregular contour, the three-dimensional location in the wrist of the scaphoid and the overlap of the carpal bones render interpretation of scaphoid radiographs difficult, especially in the absence of fracture dislocation [81,82,83].

The best diagnostic modality for confirmation of the diagnosis of a carpal fracture that is not visible on the initial radiograph is still the subject of debate. As found in previous reviews (Table 1), MRI, CT and BS have been shown to have better diagnostic performance than isolated repeated scaphoid radiographs. Previous reviews by Yin et al. concluded that BS and MRI have equally high pooled sensitivity and high diagnostic value for excluding scaphoid fracture, when the lack of a reference standard is acknowledged [35, 36]. However, MRI is more specific and better for confirming scaphoid fractures when compared to BS. According to the Cochrane review of Mallee et al., statistically BS is the best diagnostic modality for establishing a definitive diagnosis in clinically suspected fractures when radiographs appear normal, but the number of overtreated patients is substantially lower with CT and MRI [39]. Moreover, physicians must keep in mind that BS is more invasive than the other modalities. Previous reviews by Kwee et al. and Ali et al. concluded that US can diagnose occult scaphoid fracture with a fairly high degree of accuracy and Kwee et al. stated that US may be used when CT and MRI are not readily available [37, 38]. Nonetheless, one needs to keep in mind that, although scaphoid fractures are the most frequently injured carpal bones, the consequences of fractures of other carpal bones should not be underestimated. All previously available systematic reviews only examined diagnostic tests for scaphoid fractures [32,33,34,35,36,37,38,39], while in practice it is often not quite clear during the diagnostic process which hand or wrist anatomical structure or tissue (soft tissue or bone) is affected.

Conclusion

As no studies in non-institutionalized general practitioner care were identified, general practitioners who examine patients with a suspected hand or wrist fracture have limited instruments for providing adequate diagnostics. A general practitioner could decide to refer such patients to a hospital for specialized care, but one could question what assessments a specialist can use to come to an accurate diagnosis. In hospital care, two studies of the diagnostic accuracy of history taking for phalangeal, metacarpal and carpal fractures were found and physical examination was of moderate use for diagnosing a scaphoid fracture and of limited use for diagnosing phalangeal, metacarpal and remaining carpal fractures. Based on the best evidence synthesis, imaging tests (conventional radiograph, MRI, CT and BS) were only found to be moderately accurate for definitive diagnosis in hospital care.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ASB:

Anatomic snuff-box

BS:

Bone scintigraphy

BUS:

Bedside ultra sonography

CBCT::

Cone beam computer tomography

CT:

Computed tomography

HR:

High risk

HSR-S:

High spatial resolution-sonography

LR:

Likelihood ratio

LTC:

Longitudinal (thumb) compression test

MDCT:

Multi detector computed tomography

MRI:

Magnetic resonance imaging

MSCT:

Multi-slice computer tomography

NPV:

Negative predictive value

PPV:

Positive predictive value

QUADAS:

Quality Assessment of diagnostic accuracy studies

ROM:

Range of motion

Se:

Sensitivity

Sp:

Specificity

STT:

Scaphoid tubercle tenderness

T:

Tesla

UR:

Unclear Risk

US:

Ultra sonography

VAS:

Visual analogue scale

WBT:

Water bath technique

References

  1. Owen RA, Melton LJ III, Johnson KA, Ilstrup DM, Riggs BL. Incidence of Colles fracture in a north American community. Am J Public Health. 1982;72:605–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Larsen CF, Mulder S, Johansen AM, Stam C. The epidemiology of hand injuries in The Netherlands and Denmark. Eur J Epidemiol. 2004;19(4):323–7.

    Article  PubMed  Google Scholar 

  3. McCullough NP, Smith FW, Cooper JG. Early MRI in the management of the clinical scaphoid fracture. Eur J Emerg Med. 2011;18(3):133–6.

    Article  PubMed  Google Scholar 

  4. van der Molen AB, Groothoff JW, Visser GJ, Robinson PH, Eisma WH. Time off work due to scaphoid fractures and other carpal injuries in the Netherlands in the period 1990 to 1993. J Hand Surg Br. 1999;24(2):193–8.

    Article  PubMed  Google Scholar 

  5. Hey HWD, Chong AKS, Murphy D. Prevalence of carpal fracture in Singapore. J Hand Surg Am. 2011;36(2):278–83.

    Article  PubMed  Google Scholar 

  6. Van Onselen EB, Karim RB, Hage JJ, Ritt MJ. Prevalence and distribution of hand fractures. J Hand Surg Br. 2003;28(5):491–5.

    Article  PubMed  Google Scholar 

  7. Cooney WP III. Scaphoid fractures: current treatments and techniques. Instr Course Lect. 2003;52:197–208.

    PubMed  Google Scholar 

  8. Krasin E, Goldwirth M, Gold A, Goodwin DR. Review of the current methods in the diagnosis and treatment of scaphoid fractures. Postgrad Med J. 2001;77:235–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Frazier WH, Miller M, Fox RS, Brand D, Finseth F. Hand injuries: incidence and epidemiology in an emergency service. JACEP. 1978;7:265–8.

    Article  CAS  PubMed  Google Scholar 

  10. Aitken S, Court-Brown CM. The epidemiology of sports-related fractures of the hand. Injury. 2008;39:1377–83.

    Article  PubMed  Google Scholar 

  11. Van der Linden MW, Westert GP, de Bakker DH, Schellevis FG. Tweede Nationale Studie naar ziekten en verrichtingen in de huisartspraktijk. NIVEL/RIVM: Klachten en aandoeningen in de bevolking en in de huisartspraktijk. Utrecht/Bilthoven; 2004.

    Google Scholar 

  12. Roolker W, Maas M, Broekhuizen AH. Diagnosis and treatment of scaphoid fractures, can non union be prevented? Arch Orthop Trauma Surg. 1999;119:428–31.

    Article  CAS  PubMed  Google Scholar 

  13. Schaub TA, Chung KC. Systems of provision and delivery of hand care, and its impact on the community. Injury. 2006;37(11):1066–70.

    Article  PubMed  Google Scholar 

  14. de Putter CE, van Beeck EF, Polinder S, Panneman MJ, Burdorf A, Hovius SE, Selles RW. Healthcare costs and productivity costs of hand and wrist injuries by external cause: a population-based study in working-age adults in the period 2008-2012. Injury. 2016;47(7):1478–82.

    Article  PubMed  Google Scholar 

  15. Greene WB. Essentials of musculoskeletal care. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2001.

  16. Langhoff O, Andersen JL. Consequences of late immobilization of scaphoid fractures. J Hand Surg Br. 1988;13:77–9.

    Article  CAS  PubMed  Google Scholar 

  17. Eddeland A, Eiken O, Hellgren E, Ohlsson NM. Fractures of the scaphoid. Scand J Plast Reconstr Surg. 1975;9:234–9.

    Article  CAS  PubMed  Google Scholar 

  18. Taleisnik J. Clinical and technologic evaluation of ulnar wrist pain. J Hand Surg [Am]. 1988;13:801–2.

    Article  CAS  Google Scholar 

  19. Steenvoorde P, Jacobi C, van der Lecq A, van Doorn L, Kievit J, Oskam J. Development of a clinical decision tool for suspected scaphoid fractures. Acta Orthop Belg. 2006;72(4):404–10.

    PubMed  Google Scholar 

  20. Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004;70:879–84.

    PubMed  Google Scholar 

  21. Freeland P. Scaphoid tubercle tenderness: a better indicator of scaphoid fractures? Arch Emerg Med. 1989;6:46–50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Grover R. Clinical assessment of scaphoid injuries and the detection of fractures. J Hand Surg Br. 1996;21:341–3.

    Article  CAS  PubMed  Google Scholar 

  23. Groves AM, Kayani I, Syed R, Hutton BF, Bearcroft PP, Dixon AK, Ell PJ. An international survey of hospital practice in the imaging of acute scaphoid trauma. AJR Am J Roentgenol. 2006;187(6):1453–6.

    Article  PubMed  Google Scholar 

  24. Hobby JL, Tom BD, Bearcroft PW, Dixon AK. Magnetic resonance imaging of the wrist: diagnostic performance statistics. Clin Radiol. 2001;56(1):50–7.

    Article  CAS  PubMed  Google Scholar 

  25. Tiel-van Buul MM, van Beek EJ, Borm JJ, Gubler FM, Broekhuizen AH, van Royen EA. The value of radiographs and bone scintigraphy in suspected scaphoid fracture. A statistical analysis. J Hand Surg Br. 1993;18:403–6.

    Article  CAS  PubMed  Google Scholar 

  26. Hunter JC, Escobedo EM, Wilson AJ, Hanel DP, Zink-Brody GC, Mann FA. MR imaging of clinically suspected scaphoid fractures. AJR Am J Roentgenol. 1997;168:1287–93.

    Article  CAS  PubMed  Google Scholar 

  27. Furunes H, Vandvik PO. Cast immobilisation for suspected scaphoid fractures. Tidsskr Nor Laegeforen. 2009;129:177–9.

    Article  PubMed  Google Scholar 

  28. Cheung GC, Lever CJ, Morris AD. X-ray diagnosis of acute scaphoid. J Hand Surg Br. 2006;31:104–9.

    Article  CAS  PubMed  Google Scholar 

  29. Lozano-Calderon S, Blazar P, Zurakowski D, Lee SG, Ring D. Diagnosis of scaphoid fracture displacement with radiography and computed tomography. J Bone Joint Surg Am. 2006;88:2695–703.

    Article  PubMed  Google Scholar 

  30. Steel N, Abdelhamid A, Stokes T, Edwards H, Fleetcroft R, Howe A, Qureshi N. A review of clinical practice guidelines found that they were often based on evidence of uncertain relevance to primary care patients. J Clin Epidemiol. 2014;67(11):1251–7.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Ring D, Lozano-Calderon S. Imaging for suspected scaphoid fracture. J Hand Surg Am. 2008;33(6):954–7.

    Article  PubMed  Google Scholar 

  32. Carpenter CR, Pines JM, Schuur JD, Muir M, Calfee RP, Raja AS. Adult scaphoid fracture. Acad Emerg Med. 2014;21(2):101–21.

    Article  PubMed  Google Scholar 

  33. Burrows B, Moreira P, Murphy C, Sadi J, Walton DM. Scaphoid fractures: a higher order analysis of clinical tests and application of clinical reasoning strategies. Man Ther. 2014;19(5):372–8.

    Article  PubMed  Google Scholar 

  34. Mallee WH, Henny EP, van Dijk CN, Kamminga SP, van Enst WA, Kloen P. Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis. J Hand Surg Am. 2014;39(9):1683–91.

    Article  PubMed  Google Scholar 

  35. Yin ZG, Zhang JB, Kan SL, Wang XG. Diagnostic accuracy of imaging modalities for suspected scaphoid fractures: meta-analysis combined with latent class analysis. J Bone Joint Surg Br. 2012;94(8):1077–85.

    Article  PubMed  Google Scholar 

  36. Yin ZG, Zhang JB, Kan SL, Wang XG. Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis. Clin Orthop Relat Res. 2010;468(3):723–34.

    Article  PubMed  Google Scholar 

  37. Kwee RM, Kwee TC. Ultrasound for diagnosing radiographically occult scaphoid fracture. Skelet Radiol. 2018;47(9):1205–12.

    Article  Google Scholar 

  38. Ali M, Ali M, Mohamed A, Mannan S, Fallahi F. The role of ultrasonography in the diagnosis of occult scaphoid fractures. J Ultrason. 2018;18(75):325–31.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HCW, Doornberg JN. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD010023.

  40. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement BMJ 2009; 339: b2535.

  41. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. QUADAS-2 group. Ann Intern Med. 2011;155(8):529–36.

    Article  PubMed  Google Scholar 

  42. Devillé WL, Buntinx F, Bouter LM, Montori VM, de Vet HC, van der Windt DA, Bezemer PD. Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Med Res Methodol. 2002;2:9.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Adey L, Souer JS, Lozano-Calderon S, Palmer W, Lee SG, Ring D. Computed tomography of suspected scaphoid fractures. J Hand Surg Am. 2007;32(1):61–6.

    Article  PubMed  Google Scholar 

  44. Annamalai G, Raby N. Scaphoid and pronator fat stripes are unreliable soft tissue signs in the detection of radiographically occult fractures. Clin Radiol. 2003;58(10):798–800.

    Article  CAS  PubMed  Google Scholar 

  45. Behzadi C, Karul M, Henes FO, Laqmani A, Catala-Lehnen P, Lehmann W, Nagel HD, Adam G, Regier M. Comparison of conventional radiography and MDCT in suspected scaphoid fractures. World J Radiol. 2015;7(1):22–7.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Beeres FJ, Hogervorst M, Rhemrev SJ, den Hollander P, Jukema GN. A prospective comparison for suspected scaphoid fractures: bone scintigraphy versus clinical outcome. Injury. 2007;38(7):769–74.

    Article  CAS  PubMed  Google Scholar 

  47. Beeres FJ, Rhemrev SJ, den Hollander P, Kingma LM, Meylaerts SA, le Cessie S, Bartlema KA, Hamming JF, Hogervorst M. Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures. J Bone Joint Surg Br. 2008;90(9):1205–9.

    Article  CAS  PubMed  Google Scholar 

  48. Bergh TH, Lindau T, Soldal LA, Bernardshaw SV, Behzadi M, Steen K, Brudvik C. Clinical scaphoid score (CSS) to identify scaphoid fracture with MRI in patients with normal x-ray after a wrist trauma. Emerg Med J. 2014;31(8):659–64.

    Article  PubMed  Google Scholar 

  49. Breederveld RS, Tuinebreijer WE. Investigation of computed tomographic scan concurrent criterion validity in doubtful scaphoid fracture of the wrist. J Trauma. 2004;57(4):851–4.

    Article  CAS  PubMed  Google Scholar 

  50. Cruickshank J, Meakin A, Breadmore R, Mitchell D, Pincus S, Hughes T, Bently B, Harris M, Vo A. Early computerized tomography accurately determines the presence or absence of scaphoid and other fractures. Emerg Med Australas. 2007 Jun;19(3):223–228. Erratum in: Emerg Med Australas. 2007;19(4):387.

    PubMed  Google Scholar 

  51. Fusetti C, Poletti PA, Pradel PH, Garavaglia G, Platon A, Della Santa DR, Bianchi S. Diagnosis of occult scaphoid fracture with high-spatial-resolution sonography: a prospective blind study. J Trauma. 2005;59(3):677–81.

    CAS  PubMed  Google Scholar 

  52. Gäbler C, Kukla C, Breitenseher MJ, Trattnig S, Vécsei V. Diagnosis of occult scaphoid fractures and other wrist injuries. Are repeated clinical examinations and plain radiographs still state of the art? Langenbeck's Arch Surg. 2001;386(2):150–4.

    Article  Google Scholar 

  53. Herneth AM, Siegmeth A, Bader TR, Ba-Ssalamah A, Lechner G, Metz VM, Grabenwoeger F. Scaphoid fractures: evaluation with high-spatial-resolution US initial results. Radiol. 2001;220(1):231–5.

    Article  CAS  Google Scholar 

  54. Ilica AT, Ozyurek S, Kose O, Durusu M. Diagnostic accuracy of multidetector computed tomography for patients with suspected scaphoid fractures and negative radiographic examinations. Jpn J Radiol. 2011;29(2):98–103.

    Article  PubMed  Google Scholar 

  55. Kumar S, O'Connor A, Despois M, Galloway H. Use of early magnetic resonance imaging in the diagnosis of occult scaphoid fractures: the CAST Study (Canberra Area Scaphoid Trial). N Z Med J. 2005;118(1209):U1296.

    PubMed  Google Scholar 

  56. Mallee W, Doornberg JN, Ring D, van Dijk CN, Maas M, Goslings JC. Comparison of CT and MRI for diagnosis of suspected scaphoid fractures. J Bone Joint Surg Am. 2011;93(1):20–8.

    Article  PubMed  Google Scholar 

  57. Mallee WH, Mellema JJ, Guitton TG, Goslings JC, Ring D. Doornberg JN; science of variation group. 6-week radiographs unsuitable for diagnosis of suspected scaphoid fractures. Arch Orthop Trauma Surg. 2016;136(6):771–8.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Mallee WH, Doornberg JN, Ring D, Maas M, Muhl M, van Dijk CN, Goslings JC. Computed tomography for suspected scaphoid fractures: comparison of reformations in the plane of the wrist versus the long axis of the scaphoid. Hand (NY). 2014;9(1):117–21.

    Article  Google Scholar 

  59. Memarsadeghi M, Breitenseher MJ, Schaefer-Prokop C, Weber M, Aldrian S, Gäbler C, Prokop M. Occult scaphoid fractures: comparison of multidetector CT and MR imaging-initial experience. Radiol. 2006;240(1):169–76.

    Article  Google Scholar 

  60. Ottenin MA, Jacquot A, Grospretre O, Noël A, Lecocq S, Louis M, Blum A. Evaluation of the diagnostic performance of tomosynthesis in fractures of the wrist. AJR Am J Roentgenol. 2012;198(1):180–6.

    Article  PubMed  Google Scholar 

  61. Platon A, Poletti PA, Van Aaken J, Fusetti C, Della Santa D, Beaulieu JY, Becker CD. Occult fractures of the scaphoid: the role of ultrasonography in the emergency department. Skelet Radiol. 2011;40(7):869–75.

    Article  Google Scholar 

  62. Rhemrev SJ, Beeres FJ, van Leerdam RH, Hogervorst M, Ring D. Clinical prediction rule for suspected scaphoid fractures: A prospective cohort study. Injury. 2010;41(10):1026–30.

    Article  CAS  PubMed  Google Scholar 

  63. Rhemrev SJ, de Zwart AD, Kingma LM, Meylaerts SA, Arndt JW, Schipper IB, Beeres FJ. Early computed tomography compared with bone scintigraphy in suspected scaphoid fractures. Clin Nucl Med. 2010;35(12):931–4.

    Article  PubMed  Google Scholar 

  64. Steenvoorde P, Jacobi C, van Doorn L, Oskam J. Pilot study evaluating a clinical decision tool on suspected scaphoid fractures. Acta Orthop Belg. 2006;72(4):411–4.

    PubMed  Google Scholar 

  65. Yıldırım A, Unlüer EE, Vandenberk N, Karagöz A. The role of bedside ultrasonography for occult scaphoid fractures in the emergency department. Ulus Travma Acil Cerrahi Derg. 2013;19(3):241–5.

    Article  PubMed  Google Scholar 

  66. de Zwart AD, Beeres FJ, Rhemrev SJ, Bartlema K, Schipper IB. Comparison of MRI, CT and bone scintigraphy for suspected scaphoid fractures. Eur J Trauma Emerg Surg. 2016;42(6):725–31.

    Article  PubMed  Google Scholar 

  67. Sharifi MD, Moghaddam HZ, Zakeri H, Ebrahimi M, Saeedian H, Hashemian AM. The accuracy of pain measurement in diagnosis of scaphoid bone fractures in patients with magnetic resonance imaging: report of 175 cases. Med Arch. 2015;69(3):161–4.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Brink M, Steenbakkers A, Holla M, de Rooy J, Cornelisse S, Edwards MJ, Prokop M. Single-shot CT after wrist trauma: impact on detection accuracy and treatment of fractures. Skelet Radiol. 2019;48(6):949–57.

    Article  Google Scholar 

  69. Neubauer J, Benndorf M, Ehritt-Braun C, Reising K, Yilmaz T, Klein C, Zajonc H, Kotter E, Langer M, Goerke SM. Comparison of the diagnostic accuracy of cone beam computed tomography and radiography for scaphoid fractures. Sci Rep. 2018;8(1):3906.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  70. Borel C, Larbi A, Delclaux S, Lapegue F, Chiavassa-Gandois H, Sans N, Faruch-Bilfeld M. Diagnostic value of cone beam computed tomography (CBCT) in occult scaphoid and wrist fractures. Eur J Radiol. 2017;97:59–64.

    Article  PubMed  Google Scholar 

  71. Balci A, Basara I, Çekdemir EY, Tetik F, Aktaş G, Acarer A, Özaksoy D. Wrist fractures: sensitivity of radiography, prevalence, and patterns in MDCT. Emerg Radiol. 2015;22(3):251–6.

    Article  PubMed  Google Scholar 

  72. Jørgsholm P, Thomsen NO, Besjakov J, Abrahamsson SO, Björkman A. The benefit of magnetic resonance imaging for patients with posttraumatic radial wrist tenderness. J Hand Surg Am. 2013;38(1):29–33.

    Article  PubMed  Google Scholar 

  73. Nikken JJ, Oei EH, Ginai AZ, Krestin GP, Verhaar JA, van Vugt AB, Hunink MG. Acute wrist trauma: value of a short dedicated extremity MR imaging examination in prediction of need for treatment. Radiol. 2005;234(1):116–24.

    Article  Google Scholar 

  74. Javadzadeh HR, Davoudi A, Davoudi F, Ghane MR, Khajepoor H, Goodarzi H, Faraji M, Mahmoudi S, Shariat SS, Emami MK. Diagnostic value of "bedside ultrasonography" and the "water bath technique" in distal forearm, wrist, and hand bone fractures. Emerg Radiol. 2014;21(1):1–4.

    Article  PubMed  Google Scholar 

  75. Faccioli N, Foti G, Barillari M, Atzei A, Mucelli RP. Finger fractures imaging: accuracy of cone-beam computed tomography and multislice computed tomography. Skelet Radiol. 2010;39(11):1087–95.

    Article  Google Scholar 

  76. Kocaoğlu S, Özhasenekler A, İçme F, Pamukçu Günaydın G, Şener A, Gökhan Ş. The role of ultrasonography in the diagnosis of metacarpal fractures. Am J Emerg Med. 2016;34(9):1868–71.

    Article  PubMed  Google Scholar 

  77. Tayal VS, Antoniazzi J, Pariyadath M, Norton HJ. Prospective use of ultrasound imaging to detect bony hand injuries in adults. J Ultrasound Med. 2007;26(9):1143–8.

    Article  PubMed  Google Scholar 

  78. Worster A, Carpenter C. Incorporation bias in studies of diagnostic tests: how to avoid being biased about bias. CJEM. 2008;10(2):174–5.

    Article  PubMed  Google Scholar 

  79. William DM, Kurtz BK, Hertzberg BS. In: Yımaz C, editor. Bilinmesi Gerekenler-Ultrason. Çev. Ed. 2. Baskı. İzmir: Güven Bilimsel; 2008:3–4.

  80. Dias J, Kantharuban S. Treatment of scaphoid fractures: European approaches. Hand Clin. 2017;33(3):501–9.

    Article  PubMed  Google Scholar 

  81. Low G, Raby N. Can follow-up radiography for acute scaphoid fracture still be considered a valid investigation? Clin Radiol. 2005;60:1106–10.

    Article  CAS  PubMed  Google Scholar 

  82. Munk B, Frokjaer J, Larsen CF, Johannsen HG, Rasmussen LL, Edal A, Rasmussen LD. Diagnosis of scaphoid fractures. A prospective multicenter study of 1,052 patients with 160 fractures. Acta OrthopScand. 1995;66:359–60.

    CAS  Google Scholar 

  83. Tiel-van Buul MM, van Beek EJ, Broekhuizen AH, Nooitgedacht EA, Davids PH, Bakker AJ. Diagnosing scaphoid fractures: radiographs cannot be used as a gold standard! Injury. 1992;23:77–9.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

The authors thank Wichor Bramer (Biomedical information specialist of Erasmus MC University Medical Center Rotterdam, Medical Library) for help with the electronic search strategies and Yassine Aaboubout (MSc) for helping with study selection and extracting the data.

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Authors and Affiliations

  1. Department of General Practice, Erasmus MC University Medical Center Rotterdam, Room NA1911 PO Box 2040, 3000, CA, Rotterdam, the Netherlands

    Patrick Krastman & Jos Runhaar

  2. Department of Orthopaedic Surgery, Reinier de Graaf Groep, Reinier de Graafweg 5-11, 2625, AD, Delft, the Netherlands

    Nina M. Mathijssen & Gerald Kraan

  3. Department of Orthopaedics, Erasmus MC University Medical Center Rotterdam, Room NA1920 PO Box 2040, 3000, CA, Rotterdam, the Netherlands

    Sita M. A. Bierma-Zeinstra

  4. Department of General Practice, Erasmus MC University Medical Center Rotterdam, Room NA1920 PO Box 2040, 3000, CA, Rotterdam, the Netherlands

    Sita M. A. Bierma-Zeinstra

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PK, NM, SB, GK and JR all contributed to the design of the study. PK and JR were responsible for article selection and analysed the data. All authors contributed to writing and revision of the manuscript. All authors have given approval of the submitted version of the manuscript and agree to be accountable for all aspects of the work.

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Krastman, P., Mathijssen, N.M., Bierma-Zeinstra, S.M.A. et al. Diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures: a systematic review update. BMC Musculoskelet Disord 21, 12 (2020). https://doi.org/10.1186/s12891-019-2988-z

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Keywords

  • Diagnostic tests
  • Finger
  • Fracture
  • Hand
  • Wrist

BMC Musculoskeletal Disorders

ISSN: 1471-2474

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