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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 testReference testFractureSe % (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: 3,0MRIScaphoid100100   
4,5MRIScaphoid9492   
5,5MRIScaphoid9482   
6,5MRIScaphoid9472   
7,5MRIScaphoid8843   
8,5MRIScaphoid7528   
9,5MRIScaphoid3113   
 Physical examination
  Bergh (2014) [44]Clinical Scaphoid Score ≥4MRI 1,5TScaphoid7756581496
  Gabler (2001) [45]Repeated clinical and radiological examinations (after 10 days)MRI 1,0TScaphoid82    
Repeated clinical and radiological examinations (after 38 days)MRI 1,0TScaphoid100100100100100
Repeated clinical and radiological examinations (after 38 days)MRI 1,0TCapitate100    
Repeated clinical and radiological examinations (after 38 days)MRI 1,0TTriquetrum75    
Repeated clinical and radiological examinations (after 38 days)MRI 1,0THamate100    
Repeated clinical and radiological examinations (after 38 days)MRI 1,0TLunate100    
Repeated clinical and radiological examinations (after 38 days)MRI 1,0TTrapezoid100    
  Herneth (2001) [47]Clinical examinationMRIScaphoid8950737375
  Rhemrev (2010) [63]Pronation strength ≤10%Clinical follow-upScaphoid6965   
Extension < 50%Clinical follow-upScaphoid8559   
Supination strength ≤10%Clinical follow-upScaphoid8577   
Grip strength ≤25%Clinical follow-upScaphoid9234   
extension <50%, supination strength <10% and presence of a previous fracture of either the involved or uninvolved hand or wrist.Clinical follow-upScaphoid1598 6185
extension <50%, supination strength <10% and presence of a previous fracture of either the involved or uninvolved hand or wrist.Clinical follow-upNo scaphoid fracture4692 5489
Steenvoorde (2006) [64]Seven clinical tests (≥ 5 positive tests)Clinical follow-upScaphoid100135552100
 Imaging: Radiographs
  Annamalai (2003) [44]Scaphoid fat stripe on radiographyMRI 0,2T (12-72h)Scaphoid5050505050
Pronator fat stripe on radiography Scaphoid2670484649
  Balci (2015) [71]RadiographsMDCTScaphoid6698 7796
RadiographsMDCTLunate20100 10097
RadiographsMDCTTriquetrum29100 10096
RadiographsMDCTPisiform0100 099
RadiographsMDCTTrapezium1899 3398
RadiographsMDCTTrapezoid0100 099
RadiographsMDCTCapitate8100 5098
RadiographsMDCTHamata41100 7898
  Behzadi (2015) [45]Radiographs (anterior-posterior, lateral and oblique projections)MDCT (within 10 days)Scaphoid4381605373
  Herneth (2001) [53]RadiographsMRIScaphoid561007310060
  Jorgsholm (2013) [72]RadiographsMRI 0.23T (within 3 days)Scaphoid70 (61-78)98 (95-100)879782
Radiographs 6-week: DICOM viewerMRI 0.23T (within 3 days)Triquetrum59 (33-82)    
Radiographs 6-week: DICOM viewerMRI 0.23T (within 3 days)Lunate25 (1-81)    
Radiographs 6-week: DICOM viewerMRI 0.23T (within 3 days)Capitate7 (0-34)    
Radiographs 6-week: DICOM viewerMRI 0.23T (within 3 days)Hamata0 (0-46)    
  Mallee (2016) [57]Radiographs 6-week: JPEGMRIScaphoid42 (37-47)56 (54-59)53 (51-56)20 (17-23)79 (76-81)
Radiographs 6-week: JPEGMRIScaphoid64 (57-71)53 (50-57)56 (52-59)26 (22-30)85 (82-88)
  Mallee (2016) [57]Radiographs 6-week: JPEGCTScaphoid56 (50-62)59 (56-61)58 (56-61)19 (16-22)89 (87-90)
  Mallee (2016) [57]Radiographs 6-week: DICOM viewerCTScaphoid79 (72-85)55 (51-58)58 (55-61)23 (19-27)94 (91-96)
  Mallee (2016) [57]Radiographs 6-week: JPEGMRI + CTScaphoid52 (45-59)58 (55-60)57 (55-59)14 (12-17)90 (88-92)
  Mallee (2016) [57]Radiographs 6-week: DICOM viewerMRI + CTScaphoid75 (67-83)53 (50-56)56 (52-59)18 (14-21)94 (92-96)
  Ottenin 2012 [60]RadiographsClinical follow-upScaphoid67ɸ93ɸ88ɸ68ɸ92ɸ
  Ottenin 2012 [60]RadiographsClinical follow-upOther carpal bones40ɸ94ɸ88ɸ44ɸ93ɸ
  Brink (2019) [68]X-ray1-year clinical follow-upScaphoid2597   
X-ray1-year clinical follow-upTriquetral18100   
X-ray1-year clinical follow-upLunate0100   
X-ray1-year clinical follow-upTrapezium0100   
X-ray1-year clinical follow-upTrapezoid0100   
X-ray1-year clinical follow-upHamate100100   
X-ray1-year clinical follow-upCapitate100100   
  Neubauer (2018) [69]RadiographyClinical follow-upScaphoid87 (83-92)77 (71-83)8280 (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-upScaphoid80 (56-94)100 (96-100)96100 (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 fractureScaphoid100b100b100b100b100b
  Mallee (2011) [56]MRI 1.0TRadiographsScaphoid67898557
54c
93
93d
  Memarsadeghi (2006) [59]MRI 1,0TRadiographs obtained 6 weeks after trauma.All scaphoid100 (82-100)100 (87-100)100100100
  Memarsadeghi (2006) [59]MRI 1,0TRadiographs obtained 6 weeks after trauma.Cortical scaphoid fractures38 (16-65)100 (52-100)55 (24-85)10027
  Memarsadeghi (2006) [59]MRI 1,0TRadiographs obtained 6 weeks after trauma.Other carpal fractures8510084  
  de Zwart (2016) [66]MRI (<72h)Final diagnosis after MRI, CT, BS and 6-weeks clinical signsScaphoid67100 (88-100)946797
 Imaging: (Multi detector) computed tomography
  Adey (2007) [43]CT (first round interpretation)Radiographs 6 weeks after injuryScaphoid89 (84-92)91 (86-94)89 (89-92)28 (23-32)99 (97-99)
CT (second round interpretation)Radiographs 6 weeks after injuryScaphoid97 (93-99)85 (77-89)88 (82-91)  
  Breederveld (2004) [49]CTClinical follow-upScaphoid100100100100100
  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)98100 (78-100)97 (82-100)
  Ilica (2011) [54]MDCTMRI 1,5TScaphoid861009510091
  Jorgsholm (2013) [72]CTMRI 0.23T (within 3 days)Scaphoid95 (91-97)    
CTMRI 0.23T (within 3 days)Capitate75 (35-97)    
CTMRI 0.23T (within 3 days)Hamata100 (40-100)    
  Mallee (2011) [56]CTRadiographsScaphoid67969180
76c
93
94d
  Mallee (2014) [58]CT-scaphoid: reformations in planes defined by the long axis of the scaphoidRadiographsScaphoid67969180
76c
93
94d
CT-wrist: reformations made in the anatomic planes of the wristRadiographsScaphoid33897940
36c
86
87d
  Memarsadeghi (2006) [59]MDCTRadiographs obtained 6 weeks after trauma.All scaphoid73 (48-89)100 (87-100)89 (78-100)10086
  Memarsadeghi (2006) [59]MDCTRadiographs obtained 6 weeks after trauma.Cortical scaphoid fractures100 (75-100)100 (52-100)100100100
  Ottenin (2012) [60]MDCTClinical follow-upScaphoid77ɸ94ɸ91ɸ76ɸ95ɸ
  Ottenin (2012) [60]MDCTClinical follow-upOther carpal bones60ɸ95ɸ91ɸ56ɸ96ɸ
  Rhemrev (2007) [63]MDCT (<24h)Final diagnosis after CT, BS and, both radiographic (6 weeks after injury) and physical reevaluation.Scaphoid6499949094
  de Zwart (2016) [66]CT(<72h)Final diagnosis after MRI, CT, BS and 6-weeks clinical signsScaphoid33100 (88-100)9410094
  Brink (2019) [68]CT1-year clinical follow-upScaphoid100100   
CT1-year clinical follow-upTriquetral100100   
CT1-year clinical follow-upLunate100100   
CT1-year clinical follow-upTrapezium100100   
CT1-year clinical follow-upTrapezoid100100   
CT1-year clinical follow-upHamate100100   
CT1-year clinical follow-upCapitate1000   
  Neubauer (2018) [69]CBCTClinical follow-upScaphoid93 (89-96)96 (93-99)9496 (93-99)92 (89-96)
  Borel (2017) [70]CBCTMRIScaphoid cortical fracture100 (75-100)97 (83-100) 94 (68-100)100 (87-100)
CBCTMRIAll scaphoid fractures94 (68-100)97 (83-100) 94 (68-100)97 (82-100)
CBCTMRIWrist cortical fracture100 (83-100)95 (75-100) 96 (78-100)100 (83-100)
CBCTMRIAll wrist fractures89 (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 outcomeScaphoid928788a69a97
Bone scintigraphy (3-7 days after injury)Clinical outcomeScaphoid and other carpal bones9659a80a7593a
  Beeres (2008) [47]Bone scintigraphy (between 3 and 5 days)A combination of MRI, bone scintigraphy and when not in agreement, clinical follow-upScaphoid100 (83-100)90 (81-96)9271 (52-87)100 (95-100)
  Breederveld (2004) [49]Bone scintigraphy (three-fase)Clinical follow-upScaphoid7890867890
  Rhemrev (2010) [62]Bone scintigraphy (3-5 days)Final diagnosis after CT, BS and, both radiographic (6 weeks after injury) and physical reevaluation.Scaphoid9391916299
  de Zwart (2016) [66]Bone Scintigraphy (between 3 and5 days)l diagnosis after MRI, CT, BS and 6-weeks clinical signsScaphoid10097 (83-100)9775100
 Imaging: Ultrasonography
  Fusetti (2005) [51]HSR-S global evaluationCT (immediately after HSR-S performed)Scaphoid100798356100
HSR-S scaphoid cortical disruptionCT (immediately after HSR-S performed)Scaphoid100959683100
HSR-S radioarpal (RS) effusionCT (immediately after HSR-S performed)Scaphoid100425431100
HSR-S scapho-trapezium-trapezoid (STT) effusionCT (immediately after HSR-S performed)Scaphoid100848862100
HSR-S cortical disruption with RS and STT effusion (high index of suspicion)CT (immediately after HSR-S performed)Scaphoid100100100100100
  Herneth (2001) [53]USMRIScaphoid781008710075
  Javadzadeh (2014) [74]BUSRadiographsCarpal bones42 (23-64)87 (74-94)74 (62-83)57 (33-79)78 (65-88)
  Javadzadeh (2014) [74]WBT ultrasonographyRadiographsCarpal bones47 (27-68)87 (74-94)75 (64-84)60 (36-80)80 (67-89)
  Platon (2011) [61]USCTScaphoid9271764697
USCTScaphoid fracture with a high potential of complication100677130100
  Yildirim (2013) [65]BUSMRI (<24h)Scaphoid100 (69-100)34 (19-52)4930 (16-49)100 (74-100)
 Imaging: Tomosynthesis
  Ottenin (2012) [60]TomosynthesisClinical follow-upScaphoid91ɸ98ɸ96ɸ90ɸ98ɸ
  Ottenin (2012) [60]TomosynthesisClinical follow-upOther carpal bones80ɸ98ɸ96ɸ83ɸ98ɸ
Scaphoid, other carpal bones and/or metacarpal fractures
 Physical examination
  Nikken (2005) [73]Anatomic snuffbox tendernessAdditional treatment needScaphoid and other carpal bones. Metacarpal bones II–IV3978625665
 Imaging: Radiographs
  Balci (2015) [71]RadiographsMDCTMetacarpal6799 8298
  Jorgsholm (2013) [72]RadiographsMRI 0.23T (within 3 days)Metacarpal30 (7-65)    
  Nikken (2005) [73]RadiographsAdditional treatment needScaphoid and other carpal bones. Metacarpal bones II–IV7292848782
  Brink (2019) [68]X-ray1-year clinical follow-upMetacarpal67100   
 Imaging: MRI
  Nikken (2005) [73]MRIAdditional treatment needScaphoid and other carpal bones. Metacarpal bones II–IV6776736379
 Imaging: CT
  Brink (2019) [68]CT1-year clinical follow-upMetacarpal100100   
Metacarpal bones and finger fractures
 Physical examination
  Tayal (2007) [77]Physical examination: deformityRadiographs and surgical findingsMetacarpal bones and phalanx55 (44-66)89 (83-96)7677 (68-87)75 (65-85)
Physical examination: swellingRadiographs and surgical findingsMetacarpal bones and phalanx94 (88-99)13 (5-20)4541 (30-52)75 (65-85)
Physical examination: erythemaRadiographs and surgical findingsMetacarpal bones and phalanx26 (16-36)85 (77-93)6253 (42-54)63 (53-74)
 Imaging: Ultrasonography
  Tayal (2007) [77]USRadiographs and surgical findingsMetacarpal bones and phalanx90 (74-97)98 (95-100)9597 (93-100)94 (89-99)
  Javadzadeh (2014) [74]BUSRadiographsMetacarpal bones73 (43-90)78 (45-94)70 (48-85)80 (49-94)70 (40-89)
BUSRadiographsPhalanx83 (61-94)90 (78-96)88 (78-94)79 (57-91)93 (81-97)
WBT ultrasonographyRadiographsMetacarpal bones82 (52-95)89 (57-98)70 (48-85)90 (60-98)80 (49-94)
WBT ultrasonographyRadiographsPhalanx94 (74-99)95 (84-99)95 (86-98)89 (87-100)98 (87-100)
  Kocaoglu (2016) [76]USRadiographsMetacarpal bones93 (79-98)98 (90-100)9697 (85-100)95 (85-98)
 Imaging: CBCT
  Faccioli (2010) [75]CBCTMSCTArticular involvement of the phalanx100100100100100
CBCTMSCTPhalangeal bone fragments871009210082
  1. 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
  2. aOne patient had a physical examination matching with another carpal fracture instead of a scaphoid fracture at both 2 and 6 weeks after injury
  3. bFour patient did not receive MRI during follow-up (reference standard)
  4. cPositive predictive value accounting for prevalence and incidence
  5. dNegative predictive value accounting for prevalence and incidence
  6. 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
  7. ɸ Average between presented individual values of three readers (junior radiologist, junior orthopedic surgeon and senior radiologist)