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

Krastman, Patrick; Mathijssen, Nina M.; Bierma-Zeinstra, Sita M. A.; Kraan, Gerald; Runhaar, Jos

doi:10.1186/s12891-019-2988-z

Table 5 Diagnostic Accuracy of the Diagnostic Tests of the Carpal, Metacarpal and Phalangeal Fractures (N=35)

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

Author(s)	Index test	Reference test	Fracture	Se % (95% CI)	Sp % (95% CI)	Accuracy % (95% CI)	PPV % (95% CI)	NPV % (95% CI)
Scaphoid and other carpal bones fractures
History taking
Sharifi (2015) [74]	VAS pain score cutt of: 3,0	MRI	Scaphoid	100	100
	4,5	MRI	Scaphoid	94	92
	5,5	MRI	Scaphoid	94	82
	6,5	MRI	Scaphoid	94	72
	7,5	MRI	Scaphoid	88	43
	8,5	MRI	Scaphoid	75	28
	9,5	MRI	Scaphoid	31	13
Physical examination
Bergh (2014) [44]	Clinical Scaphoid Score ≥4	MRI 1,5T	Scaphoid	77	56	58	14	96
Gabler (2001) [45]	Repeated clinical and radiological examinations (after 10 days)	MRI 1,0T	Scaphoid	82
	Repeated clinical and radiological examinations (after 38 days)	MRI 1,0T	Scaphoid	100	100	100	100	100
	Repeated clinical and radiological examinations (after 38 days)	MRI 1,0T	Capitate	100
	Repeated clinical and radiological examinations (after 38 days)	MRI 1,0T	Triquetrum	75
	Repeated clinical and radiological examinations (after 38 days)	MRI 1,0T	Hamate	100
	Repeated clinical and radiological examinations (after 38 days)	MRI 1,0T	Lunate	100
	Repeated clinical and radiological examinations (after 38 days)	MRI 1,0T	Trapezoid	100
Herneth (2001) [47]	Clinical examination	MRI	Scaphoid	89	50	73	73	75
Rhemrev (2010) [63]	Pronation strength ≤10%	Clinical follow-up	Scaphoid	69	65
	Extension < 50%	Clinical follow-up	Scaphoid	85	59
	Supination strength ≤10%	Clinical follow-up	Scaphoid	85	77
	Grip strength ≤25%	Clinical follow-up	Scaphoid	92	34
	extension <50%, supination strength <10% and presence of a previous fracture of either the involved or uninvolved hand or wrist.	Clinical follow-up	Scaphoid	15	98		61	85
	extension <50%, supination strength <10% and presence of a previous fracture of either the involved or uninvolved hand or wrist.	Clinical follow-up	No scaphoid fracture	46	92		54	89
Steenvoorde (2006) [64]	Seven clinical tests (≥ 5 positive tests)	Clinical follow-up	Scaphoid	100	13	55	52	100
Imaging: Radiographs
Annamalai (2003) [44]	Scaphoid fat stripe on radiography	MRI 0,2T (12-72h)	Scaphoid	50	50	50	50	50
Annamalai (2003) [44]	Pronator fat stripe on radiography		Scaphoid	26	70	48	46	49
Balci (2015) [71]	Radiographs	MDCT	Scaphoid	66	98		77	96
	Radiographs	MDCT	Lunate	20	100		100	97
	Radiographs	MDCT	Triquetrum	29	100		100	96
	Radiographs	MDCT	Pisiform	0	100		0	99
	Radiographs	MDCT	Trapezium	18	99		33	98
	Radiographs	MDCT	Trapezoid	0	100		0	99
	Radiographs	MDCT	Capitate	8	100		50	98
	Radiographs	MDCT	Hamata	41	100		78	98
Behzadi (2015) [45]	Radiographs (anterior-posterior, lateral and oblique projections)	MDCT (within 10 days)	Scaphoid	43	81	60	53	73
Herneth (2001) [53]	Radiographs	MRI	Scaphoid	56	100	73	100	60
Jorgsholm (2013) [72]	Radiographs	MRI 0.23T (within 3 days)	Scaphoid	70 (61-78)	98 (95-100)	87	97	82
	Radiographs 6-week: DICOM viewer	MRI 0.23T (within 3 days)	Triquetrum	59 (33-82)
	Radiographs 6-week: DICOM viewer	MRI 0.23T (within 3 days)	Lunate	25 (1-81)
	Radiographs 6-week: DICOM viewer	MRI 0.23T (within 3 days)	Capitate	7 (0-34)
	Radiographs 6-week: DICOM viewer	MRI 0.23T (within 3 days)	Hamata	0 (0-46)
Mallee (2016) [57]	Radiographs 6-week: JPEG	MRI	Scaphoid	42 (37-47)	56 (54-59)	53 (51-56)	20 (17-23)	79 (76-81)
Mallee (2016) [57]	Radiographs 6-week: JPEG	MRI	Scaphoid	64 (57-71)	53 (50-57)	56 (52-59)	26 (22-30)	85 (82-88)
Mallee (2016) [57]	Radiographs 6-week: JPEG	CT	Scaphoid	56 (50-62)	59 (56-61)	58 (56-61)	19 (16-22)	89 (87-90)
Mallee (2016) [57]	Radiographs 6-week: DICOM viewer	CT	Scaphoid	79 (72-85)	55 (51-58)	58 (55-61)	23 (19-27)	94 (91-96)
Mallee (2016) [57]	Radiographs 6-week: JPEG	MRI + CT	Scaphoid	52 (45-59)	58 (55-60)	57 (55-59)	14 (12-17)	90 (88-92)
Mallee (2016) [57]	Radiographs 6-week: DICOM viewer	MRI + CT	Scaphoid	75 (67-83)	53 (50-56)	56 (52-59)	18 (14-21)	94 (92-96)
Ottenin 2012 [60]	Radiographs	Clinical follow-up	Scaphoid	67ɸ	93ɸ	88ɸ	68ɸ	92ɸ
Ottenin 2012 [60]	Radiographs	Clinical follow-up	Other carpal bones	40ɸ	94ɸ	88ɸ	44ɸ	93ɸ
Brink (2019) [68]	X-ray	1-year clinical follow-up	Scaphoid	25	97
	X-ray	1-year clinical follow-up	Triquetral	18	100
	X-ray	1-year clinical follow-up	Lunate	0	100
	X-ray	1-year clinical follow-up	Trapezium	0	100
	X-ray	1-year clinical follow-up	Trapezoid	0	100
	X-ray	1-year clinical follow-up	Hamate	100	100
	X-ray	1-year clinical follow-up	Capitate	100	100
Neubauer (2018) [69]	Radiography	Clinical follow-up	Scaphoid	87 (83-92)	77 (71-83)	82	80 (75-86)	84 (80-90)
Imaging: MRI
Beeres (2008) [47]	MRI 1,5T (<24h)	A combination of MRI, bone scintigraphy and when not in agreement, clinical follow-up	Scaphoid	80 (56-94)	100 (96-100)	96	100 (74-100)	95 (88-99)
Kumar (2005) [55]	MRI 1,5T (<24h)	MRI in those without fracture at MRI <24h or no clinical signs of fracture	Scaphoid	100^b	100^b	100^b	100^b	100^b
Mallee (2011) [56]	MRI 1.0T	Radiographs	Scaphoid	67	89	85	57 54^c	93 93^d
Memarsadeghi (2006) [59]	MRI 1,0T	Radiographs obtained 6 weeks after trauma.	All scaphoid	100 (82-100)	100 (87-100)	100	100	100
Memarsadeghi (2006) [59]	MRI 1,0T	Radiographs obtained 6 weeks after trauma.	Cortical scaphoid fractures	38 (16-65)	100 (52-100)	55 (24-85)	100	27
Memarsadeghi (2006) [59]	MRI 1,0T	Radiographs obtained 6 weeks after trauma.	Other carpal fractures	85	100	84
de Zwart (2016) [66]	MRI (<72h)	Final diagnosis after MRI, CT, BS and 6-weeks clinical signs	Scaphoid	67	100 (88-100)	94	67	97
Imaging: (Multi detector) computed tomography
Adey (2007) [43]	CT (first round interpretation)	Radiographs 6 weeks after injury	Scaphoid	89 (84-92)	91 (86-94)	89 (89-92)	28 (23-32)	99 (97-99)
Adey (2007) [43]	CT (second round interpretation)	Radiographs 6 weeks after injury	Scaphoid	97 (93-99)	85 (77-89)	88 (82-91)
Breederveld (2004) [49]	CT	Clinical follow-up	Scaphoid	100	100	100	100	100
Cruickshank (2007) [50]	CT (same or next day)	The diagnosis on Day 10 with clinical examination and X-rays, with MRI performed in patients with persistent tenderness but normal X-rays.	Scaphoid and other fractures (Triquetral, Trapezium, Capitate and Lunate)	94 (72-100)	100 (87-100)	98	100 (78-100)	97 (82-100)
Ilica (2011) [54]	MDCT	MRI 1,5T	Scaphoid	86	100	95	100	91
Jorgsholm (2013) [72]	CT	MRI 0.23T (within 3 days)	Scaphoid	95 (91-97)
	CT	MRI 0.23T (within 3 days)	Capitate	75 (35-97)
	CT	MRI 0.23T (within 3 days)	Hamata	100 (40-100)
Mallee (2011) [56]	CT	Radiographs	Scaphoid	67	96	91	80 76^c	93 94^d
Mallee (2014) [58]	CT-scaphoid: reformations in planes defined by the long axis of the scaphoid	Radiographs	Scaphoid	67	96	91	80 76^c	93 94^d
Mallee (2014) [58]	CT-wrist: reformations made in the anatomic planes of the wrist	Radiographs	Scaphoid	33	89	79	40 36^c	86 87^d
Memarsadeghi (2006) [59]	MDCT	Radiographs obtained 6 weeks after trauma.	All scaphoid	73 (48-89)	100 (87-100)	89 (78-100)	100	86
Memarsadeghi (2006) [59]	MDCT	Radiographs obtained 6 weeks after trauma.	Cortical scaphoid fractures	100 (75-100)	100 (52-100)	100	100	100
Ottenin (2012) [60]	MDCT	Clinical follow-up	Scaphoid	77ɸ	94ɸ	91ɸ	76ɸ	95ɸ
Ottenin (2012) [60]	MDCT	Clinical follow-up	Other carpal bones	60ɸ	95ɸ	91ɸ	56ɸ	96ɸ
Rhemrev (2007) [63]	MDCT (<24h)	Final diagnosis after CT, BS and, both radiographic (6 weeks after injury) and physical reevaluation.	Scaphoid	64	99	94	90	94
de Zwart (2016) [66]	CT(<72h)	Final diagnosis after MRI, CT, BS and 6-weeks clinical signs	Scaphoid	33	100 (88-100)	94	100	94
Brink (2019) [68]	CT	1-year clinical follow-up	Scaphoid	100	100
	CT	1-year clinical follow-up	Triquetral	100	100
	CT	1-year clinical follow-up	Lunate	100	100
	CT	1-year clinical follow-up	Trapezium	100	100
	CT	1-year clinical follow-up	Trapezoid	100	100
	CT	1-year clinical follow-up	Hamate	100	100
	CT	1-year clinical follow-up	Capitate	100	0
Neubauer (2018) [69]	CBCT	Clinical follow-up	Scaphoid	93 (89-96)	96 (93-99)	94	96 (93-99)	92 (89-96)
Borel (2017) [70]	CBCT	MRI	Scaphoid cortical fracture	100 (75-100)	97 (83-100)		94 (68-100)	100 (87-100)
	CBCT	MRI	All scaphoid fractures	94 (68-100)	97 (83-100)		94 (68-100)	97 (82-100)
	CBCT	MRI	Wrist cortical fracture	100 (83-100)	95 (75-100)		96 (78-100)	100 (83-100)
	CBCT	MRI	All wrist fractures	89 (70-97)	95 (75-100)		96 (78-100)	88 (67-97)
Imaging: Bone scintigraphy
Beeres (2007) [46]	Bone scintigraphy (3-7 days after injury)	Clinical outcome	Scaphoid	92	87	88^a	69^a	97
Beeres (2007) [46]	Bone scintigraphy (3-7 days after injury)	Clinical outcome	Scaphoid and other carpal bones	96	59^a	80^a	75	93^a
Beeres (2008) [47]	Bone scintigraphy (between 3 and 5 days)	A combination of MRI, bone scintigraphy and when not in agreement, clinical follow-up	Scaphoid	100 (83-100)	90 (81-96)	92	71 (52-87)	100 (95-100)
Breederveld (2004) [49]	Bone scintigraphy (three-fase)	Clinical follow-up	Scaphoid	78	90	86	78	90
Rhemrev (2010) [62]	Bone scintigraphy (3-5 days)	Final diagnosis after CT, BS and, both radiographic (6 weeks after injury) and physical reevaluation.	Scaphoid	93	91	91	62	99
de Zwart (2016) [66]	Bone Scintigraphy (between 3 and5 days)	l diagnosis after MRI, CT, BS and 6-weeks clinical signs	Scaphoid	100	97 (83-100)	97	75	100
Imaging: Ultrasonography
Fusetti (2005) [51]	HSR-S global evaluation	CT (immediately after HSR-S performed)	Scaphoid	100	79	83	56	100
	HSR-S scaphoid cortical disruption	CT (immediately after HSR-S performed)	Scaphoid	100	95	96	83	100
	HSR-S radioarpal (RS) effusion	CT (immediately after HSR-S performed)	Scaphoid	100	42	54	31	100
	HSR-S scapho-trapezium-trapezoid (STT) effusion	CT (immediately after HSR-S performed)	Scaphoid	100	84	88	62	100
	HSR-S cortical disruption with RS and STT effusion (high index of suspicion)	CT (immediately after HSR-S performed)	Scaphoid	100	100	100	100	100
Herneth (2001) [53]	US	MRI	Scaphoid	78	100	87	100	75
Javadzadeh (2014) [74]	BUS	Radiographs	Carpal bones	42 (23-64)	87 (74-94)	74 (62-83)	57 (33-79)	78 (65-88)
Javadzadeh (2014) [74]	WBT ultrasonography	Radiographs	Carpal bones	47 (27-68)	87 (74-94)	75 (64-84)	60 (36-80)	80 (67-89)
Platon (2011) [61]	US	CT	Scaphoid	92	71	76	46	97
Platon (2011) [61]	US	CT	Scaphoid fracture with a high potential of complication	100	67	71	30	100
Yildirim (2013) [65]	BUS	MRI (<24h)	Scaphoid	100 (69-100)	34 (19-52)	49	30 (16-49)	100 (74-100)
Imaging: Tomosynthesis
Ottenin (2012) [60]	Tomosynthesis	Clinical follow-up	Scaphoid	91ɸ	98ɸ	96ɸ	90ɸ	98ɸ
Ottenin (2012) [60]	Tomosynthesis	Clinical follow-up	Other carpal bones	80ɸ	98ɸ	96ɸ	83ɸ	98ɸ
Scaphoid, other carpal bones and/or metacarpal fractures
Physical examination
Nikken (2005) [73]	Anatomic snuffbox tenderness	Additional treatment need	Scaphoid and other carpal bones. Metacarpal bones II–IV	39	78	62	56	65
Imaging: Radiographs
Balci (2015) [71]	Radiographs	MDCT	Metacarpal	67	99		82	98
Jorgsholm (2013) [72]	Radiographs	MRI 0.23T (within 3 days)	Metacarpal	30 (7-65)
Nikken (2005) [73]	Radiographs	Additional treatment need	Scaphoid and other carpal bones. Metacarpal bones II–IV	72	92	84	87	82
Brink (2019) [68]	X-ray	1-year clinical follow-up	Metacarpal	67	100
Imaging: MRI
Nikken (2005) [73]	MRI	Additional treatment need	Scaphoid and other carpal bones. Metacarpal bones II–IV	67	76	73	63	79
Imaging: CT
Brink (2019) [68]	CT	1-year clinical follow-up	Metacarpal	100	100
Metacarpal bones and finger fractures
Physical examination
Tayal (2007) [77]	Physical examination: deformity	Radiographs and surgical findings	Metacarpal bones and phalanx	55 (44-66)	89 (83-96)	76	77 (68-87)	75 (65-85)
	Physical examination: swelling	Radiographs and surgical findings	Metacarpal bones and phalanx	94 (88-99)	13 (5-20)	45	41 (30-52)	75 (65-85)
	Physical examination: erythema	Radiographs and surgical findings	Metacarpal bones and phalanx	26 (16-36)	85 (77-93)	62	53 (42-54)	63 (53-74)
Imaging: Ultrasonography
Tayal (2007) [77]	US	Radiographs and surgical findings	Metacarpal bones and phalanx	90 (74-97)	98 (95-100)	95	97 (93-100)	94 (89-99)
Javadzadeh (2014) [74]	BUS	Radiographs	Metacarpal bones	73 (43-90)	78 (45-94)	70 (48-85)	80 (49-94)	70 (40-89)
	BUS	Radiographs	Phalanx	83 (61-94)	90 (78-96)	88 (78-94)	79 (57-91)	93 (81-97)
	WBT ultrasonography	Radiographs	Metacarpal bones	82 (52-95)	89 (57-98)	70 (48-85)	90 (60-98)	80 (49-94)
	WBT ultrasonography	Radiographs	Phalanx	94 (74-99)	95 (84-99)	95 (86-98)	89 (87-100)	98 (87-100)
Kocaoglu (2016) [76]	US	Radiographs	Metacarpal bones	93 (79-98)	98 (90-100)	96	97 (85-100)	95 (85-98)
Imaging: CBCT
Faccioli (2010) [75]	CBCT	MSCT	Articular involvement of the phalanx	100	100	100	100	100
Faccioli (2010) [75]	CBCT	MSCT	Phalangeal bone fragments	87	100	92	100	82

BUS Bedside Ultra Sonography, CBCT Cone Beam Computed tomography arthrography, MDCT Multidetector Computed tomography, MRI Magnetic resonance imaging, T Tesla, US Ultra Sonography, HSR-S High Spatial Resolution sonography, VAS Visual Analogue Scale, Se Sensitivity, Sp Specificity, PPV Positive predictive value, NPV Negative predictive value, LR Likelihood ratio
^aOne patient had a physical examination matching with another carpal fracture instead of a scaphoid fracture at both 2 and 6 weeks after injury
^bFour patient did not receive MRI during follow-up (reference standard)
^cPositive predictive value accounting for prevalence and incidence
^dNegative predictive value accounting for prevalence and incidence
^c/dThe positive predictive value and negative predictive value were determined with use of the Bayes theorem, which requires an a priori estimate of the prevalence (pretest probability) of the presence of scaphoid fractures. The positive predictive value is the patient’s probability of having a scaphoid fracture when the test is positive, and the negative predictive value is the probability of a patient not having a scaphoid fracture when the test is negative. The predictive values of any imaging modality depend critically on the prevalence of the characteristic in the patients being tested; hence the use of the appropriate Bayesian analysis is important. For the determination of positive and negative predictive values, we estimated an average prevalence of scaphoid fractures of 16% on the basis of the best available data. The positive predictive value was calculated as sensitivity · prevalence/(sensitivity · prevalence) 1 [(1 – specificity) · (1 – prevalence)], and the negative predictive value was calculated as specificity · (1 – prevalence)/[(1 – sensitivity) · prevalence] 1 [specificity · (1 – prevalence)].^54,60
ɸ Average between presented individual values of three readers (junior radiologist, junior orthopedic surgeon and senior radiologist)

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