The scaphoid is the most commonly fractured carpal bone.[1] Scaphoid fractures account for approximately 15% of acute wrist injuries that affect
predominately young men between 15 and 30 years of age.[2]
[3] Typical mechanism of injury involves axial loading on an outstretched hand where
the forces are transferred through the second metacarpal.
The first scaphoid fracture was described in 1905 by Destot et al following the discovery
of radiography.[4] In the following years, fractures were classified into waist, distal, and proximal
pole injuries. Among patients with suspected scaphoid fractures, it is estimated that
the prevalence of true fractures is only between 5 and 10%.[2] For diagnosis, tenderness on exam at the snuffbox and the volar aspect of the distal
tuberosity, as well as scaphoid compression test, in addition to radiographic assessment,
are all essential. Because of the difficulty of making this diagnosis and the low
healing potential, scaphoid fractures are predisposed to delayed union. Nonunion rates
have been reported to be as high as 12%.[5]
[6]
In diagnosing scaphoid fractures, the clinical examination is only specific in 74
to 80% of cases with a positive predictive value of 21%.[6] This may vary between the tenderness of the scaphoid tubercle with a sensitivity
of 95.23% and specificity of 74.07%, tenderness of the anatomical snuffbox (sensitivity = 85.71%
and specificity 29.62%), or a direct compression test (sensitivity = 42.85% and specificity = 29.62%).[7] Radiographic assessment typically includes four views, which include posteroanterior,
true lateral, posteroanterior in ulnar deviation, and oblique views. These views are
sensitive in 70 to 90% of cases and miss up to 16% of cases, which is why previous
studies have recommended advanced imaging modalities.[8]
[9]
[10] Other imaging options include bone scintigraphy, magnetic resonance imaging (MRI),
computed tomography (CT), and ultrasound (US). Because of the inconsistency in data
and steadily improving imaging quality, an updated systematic review and meta-analysis
was performed.[ 2]
[10]
[11]
[12] The last reviews published on this topic included studies published up to December
2012.[10]
[11] Those authors chose similar search criteria for their literature reviews and included
between 11[10] and 75 publications,[11] and for 7 US studies.[12] However, these studies concluded that there was no real consensus on the best adjuvant
imaging modality for scaphoid fractures, although MRI was generally better at confirming
the presence of a scaphoid fracture.
The purpose of this study is to perform a systematic review of the literature concerning
the different imaging modalities for diagnosing scaphoid fracture. Additionally, a
meta-analysis including studies between 1901 and 2018 was performed.
Materials and Methods
A systematic literature search was performed on August 28, 2018, using the Medline,
PubMed, Cochrane, and Google search engine according to the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.[13] The search term “scaphoid fracture” was used because it was thought to be a broad
inclusive term. Articles in English, German, and French were included. Articles that
evaluated the sensitivity and specificity of different imaging modalities prospectively
were included. Articles that had the following criteria were excluded: duplicate results,
lack of full access to the original article, retrospective studies, biomechanical
studies, case reports, review articles, letters to the editors, or comments. All abstracts
were reviewed by two of the authors. In total, 2,818 studies were found based on our
search term, including 10 duplicates. Two hundred sixteen abstracts that included
the diagnostics of the scaphoid were reviewed. One hundred forty studies were subsequently
excluded as these did not meet inclusion criteria, leaving 76 articles for final review.
Thirty-four articles were excluded as the full text was not accessible, leaving 42
articles for inclusion in our systematic review ([Fig. 1]).
Fig. 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009
flow diagram of included articles.
Both raw and descriptive data on the demographics, imaging modality, incidence of
scaphoid fracture, specificity, sensitivity, as well as positive and negative predictive
value were collected. In studies where the raw data was listed, we calculated the
sensitivity and specificity separately. Forty of the 42 articles mentioned explicitly
that the study was performed prospectively, whereas in two studies we assumed that
this was the case.[14]
[15] Of the 42 articles, 11 studies performed comparisons between different imaging modalities.
In total, there are 51 different radiographic analyses, including 16 bone scintigraphy
studies, 14 CT studies, 12 MRI studies, and 10 US studies. In all, 2,507 patients
were included overall.
For the “gold standard” reference by which to judge whether a scaphoid fracture was
actually present, a variety of tests were used. These included a follow-up scaphoid
plain radiography in 29 cases (n = 29/42) between 2 to > 6 weeks after initial presentation in the clinic which is
often described as being the gold standard.[16]
[17] In the remaining cases either CT (n = 3),[14]
[18]
[19] MRI scan (n = 7), or bone scintigraphy was used (n = 1).[20] In plain radiographs, an abnormal lucent line within the scaphoid is considered
evidence of fracture. In two studies, the two index tests were used, which are thought
to be positive if the findings of two different modalities including clinical findings
correspond with each other, either signs of fracture (positive) or absence of a fracture
line (negative). These two index tests were applied in CT and compared with US and
MRI.[21]
[22]
Results
A total of 42 studies including 2,507 patients were investigated. In comparison to
previous systematic reviews, six additional studies were included.[23]
[24]
[25]
[26]
[27]
[28] Males were affected in 49.2% of cases and the mean age was 34.1 ± 5.7 years. The
overall incidence of occult scaphoid fractures was 21.8% (standard deviation [SD]
9.81). Occult scaphoid fractures are defined as wrist pain and scaphoid tenderness
with no visible fracture line on X-rays. In 16 publications, bone scintigraphy was
investigated. For CT scan, there were 14 publications. Twelve studies compared two
different sequences in MRI[26] and there were 10 articles that assessed the sensitivity and specificity of US.
A total of 12 studies performed comparisons between two different radiographic modalities.
Unfortunately, we were not able to obtain true and false positive values from six
studies and only the specificity and sensitivity were presented.[18]
[23]
[24]
[29]
[30]
[31] Because of this absence, the predictive values—positive as well as negative (PPV
and NPV)—were not accessible in four studies.[18]
[29]
[30]
[31]
Sensitivity was found to be highest in MRI at 94.2% (SD 10.7), followed by bone scintigraphy
at 92.8% (SD 11.4). All except three studies observed a sensitivity of < 100% for
MRI (80 or 83%), which was explained by only a short MRI scanning time of 7 minutes,[22] fibrovascular scar tissue or contrast agent diffusing from adjacent soft tissues,[26] or finally, misinterpretation of bone bruise or vascular channels.[10] Interestingly, US showed equivalent sensitivity (81.5% SD 21.2) to CT at 81.5 (SD
14.0). Statistically, bone scintigraphy (p = 0.03) and MRI (p = 0.02) have significantly higher sensitivity when compared to CT. For specificity,
MRI is highest at 97.7% (SD 4.7), followed by CT scan at 96.0% (SD 4.8) and bone scintigraphy
at 90.9% (SD 11.8). US showed a mean specificity of 77.4% (SD 18.5), which was significantly
lower than other imaging modalities; compared with MRI (p = 0.002), CT (p = 0.003) and bone scintigraphy (p = 0.04). All sensitivities and specificities including PPVs and NPVs are summarized
in [Table 1]. The individual studies are listed in [Table 2].
Table 1
All sensitivities and specificities including positive and negative predictive values
|
Number of studies
|
Number of patients
|
Sensitivity
|
Specificity
|
PPV
|
NPV
|
|
Bone scintigraphy
|
16
|
1,133
|
92.8 ± 11.4
|
90.9 ± 11.8
|
72.2 ± 22.6
|
99.2 ± 2.7
|
|
CT
|
14
|
838
|
81.5 ± 14.0
|
96.0 ± 4.8
|
83.9 ± 25.2
|
94.4 ± 4.8
|
|
MRI
|
12
|
548
|
94.2 ± 10.7
|
97.9 ± 4.7
|
95.3 ± 12.4
|
98.0 ± 3.1
|
|
Ultrasound
|
10
|
589
|
81.5 ± 21.2
|
77.4 ± 18.5
|
63.5 ± 26.4
|
88.8 ± 14.2
|
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; NPV, negative
predictive value; PPV, positive predictive value.
Table 2
Overview on the included studies in the systematic review
|
Authors
|
No
|
m/f
|
Age
|
Sensitivity
|
Specificity
|
PPV
|
NPV
|
TP
|
FP
|
FN
|
TN
|
Incidence
|
Reference
|
|
Bone scan
|
|
|
Akdemir et al 2004[32]
|
32
|
18/14
|
31
|
100
|
100
|
100
|
100
|
8
|
0
|
0
|
24
|
25
|
PR
|
|
Beeres et al 2008[22]
|
100
|
50/50
|
42
|
100
|
90
|
71
|
100
|
20
|
8
|
0
|
72
|
20
|
PR, concordance
|
|
Breederveld and Tuinebreijer 2004[14]
|
29
|
nr
|
nr
|
78
|
90
|
78
|
90
|
7
|
2
|
2
|
18
|
31
|
CT after 6 weeks
|
|
de Zwart et al 2012[33]
|
159
|
79/80
|
41
|
95
|
94
|
68
|
|
19
|
9
|
1
|
130
|
nr
|
PR
|
|
Fowler et al 1998[34]
|
43
|
21/22
|
32
|
83
|
95
|
71
|
|
5
|
2
|
1
|
35
|
14
|
PR
|
|
Groves et al 2005[35]
|
51
|
17/34
|
40.2
|
100
|
100
|
100
|
100
|
6
|
0
|
0
|
45
|
12
|
PR one case MRI follow-up
|
|
Kitsis et al 1998[36]
|
22
|
9/13
|
34
|
100
|
95
|
75
|
100
|
3
|
1
|
0
|
18
|
14
|
MRI
|
|
Murphy et al 1995[37]
|
99[a]
|
55/44
|
36
|
65
|
100
|
65
|
100
|
13
|
7
|
0
|
80
|
13
|
PR, follow-up BS
|
|
Nielsen et al 1983[38]
|
100[a]
|
61/39
|
33
|
100
|
52
|
20
|
100
|
11
|
43
|
0
|
47
|
11
|
PR
|
|
O'Carroll et al 1982[39]
|
30
|
21/9
|
32
|
100
|
79
|
55
|
100
|
6
|
5
|
0
|
19
|
nr
|
PR
|
|
Rhemrev et al 2010[21]
|
100
|
51/49
|
40.8
|
93
|
91
|
62
|
99
|
13
|
8
|
1
|
86
|
nr
|
PR, concordance
|
|
Stordahl A 1984[40]
|
30
|
18/12
|
31
|
100
|
100
|
100
|
100
|
9
|
0
|
0
|
19
|
32
|
PR
|
|
Tiel-van Buul et al 1996[41]
|
16
|
11/5
|
36
|
71
|
100
|
100
|
|
5
|
0
|
2
|
9
|
nr
|
BS
|
|
Tiel-van Buul et al 1993[42]
|
78
|
35/43
|
42
|
100
|
98
|
93
|
100
|
14
|
1
|
0
|
45
|
nr
|
PR
|
|
Tiel-van Buul et al 1993[43]
|
160
|
82/78
|
38.6
|
100
|
87
|
60
|
100
|
21
|
14
|
0
|
90
|
17
|
PR
|
|
Waizenegger et al 1994[44]
|
84
|
nr
|
nr
|
100
|
84
|
37
|
100
|
7
|
12
|
0
|
65
|
8
|
PR and CT
|
|
Total
|
1133
|
|
|
92.8
|
90.9
|
72.2
|
99.2
|
167
|
112
|
7
|
802
|
17.9
|
|
|
CT
|
|
|
Adey et al 2007[45]
|
30
|
19/11
|
33
|
85
|
88
|
|
|
|
|
|
|
nr
|
PR
|
|
Basha et al 2018[23]
|
168
|
104/64
|
38.81
|
62.5
|
97.3
|
9.9
|
85.7
|
|
|
|
|
37.5
|
PR
|
|
Borel et al 2017[24]
|
49
|
31/18
|
36
|
94
|
97
|
94
|
97
|
|
|
|
|
nr
|
MRI
|
|
Breederveld and Tuinebreijer 2004[14]
|
29
|
nr
|
nr
|
100
|
100
|
100
|
100
|
9
|
0
|
0
|
20
|
31
|
PR after 6 weeks
|
|
Cruickshank et al 2007[46]
|
47
|
26/21
|
nr
|
94
|
100
|
100
|
96.8
|
7
|
0
|
0
|
40
|
15
|
MRI
|
|
de Zwart et al 2012[33]
|
159
|
79/80
|
41
|
70
|
99
|
93
|
96
|
14
|
1
|
6
|
138
|
nr
|
PR
|
|
Groves et al 2005[47]
|
51
|
17/34
|
40.2
|
100
|
91
|
60
|
100
|
6
|
4
|
0
|
41
|
12
|
PR, one case MRI follow-up
|
|
Ilica et al 2011[48]
|
54
|
54/0
|
22
|
86
|
100
|
100
|
91
|
14
|
0
|
2
|
39
|
25.5
|
MRI follow-up
|
|
Mallee et al 2011[25]
|
34
|
25/15
|
nr
|
67
|
96
|
80
|
93
|
4
|
1
|
2
|
27
|
18
|
PR
|
|
Mallee et al 2014[35]
|
34
|
nr
|
nr
|
67
|
96
|
80
|
93
|
4
|
1
|
2
|
27
|
nr
|
PR
|
|
Memarsadeghi et al 2006[49]
|
29
|
17/12
|
34
|
73
|
100
|
100
|
86
|
8
|
0
|
3
|
18
|
nr
|
PR
|
|
Rhemrev et al 2010[21]
|
100
|
51/49
|
40.8
|
64
|
99
|
90
|
94
|
9
|
1
|
5
|
85
|
nr
|
PR, concordance
|
|
Ty et al 2008[50]
|
20
|
12/8
|
40
|
97
|
85
|
100
|
100
|
4
|
0
|
0
|
16
|
20
|
PR
|
|
Total
|
804
|
|
|
81.5
|
96
|
83.9
|
94.4
|
79
|
8
|
20
|
451
|
22.7
|
|
|
MRI
|
|
|
Beeres et al 2008[22]
|
100
|
50/50
|
42
|
80
|
100
|
100
|
95
|
16
|
0
|
4
|
80
|
20
|
PR
|
|
Breitenseher et al 1997[51]
|
42
|
23/19
|
30.5
|
100
|
100
|
100
|
100
|
14
|
0
|
0
|
28
|
33
|
PR
|
|
Bretlau et al 1999[52]
|
52
|
27/25
|
44
|
100
|
100
|
100
|
100
|
7
|
0
|
0
|
38
|
16
|
PR
|
|
Fowler et al 1998[53]
|
43
|
21/22
|
32
|
100
|
100
|
100
|
100
|
6
|
0
|
0
|
37
|
14
|
PR
|
|
Gäbler et al 2001[54]
|
118
|
74/44
|
30
|
100
|
100
|
100
|
100
|
28
|
0
|
0
|
93
|
25
|
PR
|
|
Gaebler et al 1996[55]
|
32
|
21/11
|
29.5
|
100
|
100
|
|
|
|
|
|
|
nr
|
PR
|
|
Hunter et al 1997[56]
|
36
|
28/8
|
26
|
100
|
86
|
91
|
100
|
10
|
1
|
0
|
19
|
33
|
PR 2weeks
|
|
Kitsis et al 1998[57]
|
22
|
9/13
|
34
|
100
|
100
|
100
|
100
|
3
|
0
|
0
|
19
|
14
|
MRI
|
|
Kumar et al 2005[58]
|
22
|
17/5
|
27
|
100
|
100
|
100
|
100
|
6
|
0
|
0
|
16
|
27
|
pr or re-MRI
|
|
Larribe et al 2014[59]
|
18
|
16/2
|
30.4
|
83
|
100
|
100
|
92
|
5
|
0
|
1
|
12
|
nr
|
Histology
|
|
Mallee et al 2011[25]
|
34
|
25/15
|
nr
|
67
|
89
|
57
|
93
|
4
|
3
|
2
|
25
|
18
|
pr
|
|
Memarsadeghi et al 2006[60]
|
29
|
17/12
|
34
|
100
|
100
|
100
|
|
11
|
0
|
0
|
18
|
nr
|
pr
|
|
Total
|
548
|
|
|
94.2
|
97.9
|
95.3
|
98
|
110
|
4
|
7
|
385
|
22.2
|
|
|
Ultrasound
|
|
|
Christiansen et al 1991[27]
|
103
|
55/48
|
31.4
|
37
|
61
|
22
|
100
|
10
|
30
|
17
|
46
|
27
|
pr
|
|
Fusetti et al 2005[18]
|
24
|
13/11
|
42
|
100
|
79
|
56
|
100
|
|
|
|
|
20.8
|
CT
|
|
Hauger et al 2002[61]
|
54
|
35/19
|
26
|
100
|
98
|
83
|
100
|
5
|
1
|
0
|
48
|
9.3
|
pr or other
|
|
Herneth et al 2001[62]
|
15
|
7/8
|
23.5
|
78
|
100
|
100
|
75
|
7
|
0
|
2
|
6
|
38.5
|
MRI
|
|
Hodgkinson et al 1993[31]
|
78
|
46/32
|
36.8
|
100
|
74.2
|
|
|
|
|
|
|
8.3
|
pr
|
|
Jain et al 2018[28]
|
114
|
2/1.75
|
32
|
79.8
|
76.7
|
90.5
|
57.5
|
67
|
7
|
17
|
23
|
nr
|
MRI
|
|
Munk et al 2000[15]
|
58
|
31/26
|
38
|
50
|
91
|
56
|
90
|
5
|
4
|
5
|
48
|
nr
|
pr
|
|
Platon et al 2011[19]
|
62
|
29/33
|
41.2
|
92
|
71
|
46
|
97
|
12
|
0
|
1
|
87
|
21
|
CT
|
|
Senall et al 2004[63]
|
18
|
nr
|
35
|
78
|
89
|
88
|
80
|
7
|
1
|
2
|
8
|
50
|
pr
|
|
Yıldırım et al 2013[64]
|
63
|
30/33
|
39.6
|
100
|
34.3
|
30.3
|
100
|
10
|
23
|
0
|
12
|
22.2
|
MRI
|
|
Total
|
589
|
|
|
81.5
|
77.4
|
63.5
|
88.8
|
123
|
66
|
44
|
278
|
22.6
|
|
Abbreviations: nr, not reported; pr, plain radiograph; CT, computed tomography; FN,
false negative; FP, false positive; MRI, magnetic resonance imaging; NPV, negative
predictive value; PPV, positive predictive value; TN, true negative; TP, true positive.
a Bilateral case.
Discussion
To avoid scaphoid nonunion and initiate early treatment, prompt and precise diagnosis
is essential. If initial plain radiograph imaging appears normal in suspected scaphoid
fractures, approximately 21.8% (SD 9.81) will still have a true fracture based on
our systematic review. This is an increase of 5.8% compared to earlier publications.[8]
[9] Therefore, further imaging such as bone scintigraphy, CT, magnetic resonance imaging,
and US should be considered in suspected scaphoid fractures without any visible fracture
line on plain X-rays.
Six additional publications were included in comparison to the last published systematic
reviews, which showed an overall increase in sensitivity for MRI from 88 to 94.2%
and CT from 72 to 81.5%.[10] According to our systematic review, the most sensitive and specific adjunctive tool
is the MRI at 94.2 and 97.7%, respectively. When considering that 21.8% of scaphoid
fractures are missed on initial plain radiograph in four views and the sensitivity
of CT scanning is found to be 81.5%, the sensitivity of CT scanning is only slightly
better than X-ray. However, the negative predictive value of CT scanning was found
to be 94.4 ± 4.8% which means that 94.4% of patients who have no signs of fracture
on CT do not actually have a fracture. Although the sensitivity and specificity of
CT are lower than that of MRI, it is the only modality which is quick and reliably
available in the emergency department.
After initial clinical examination, the treating surgeon has to evaluate the necessity
for further diagnostic imaging. This may include the pain score using the visual analogue
scale in patients with tenderness of the snuffbox which did not show any prognostic
factor to diagnose scaphoid fracture (sensitivity = 87% and specificity = 57% for
pain scores 7.5 and higher and 75%, respectively, 72 for scores more or equal to 8.5).[66] For clinical examination, the most accurate test is the scaphoid tubercle tenderness
that showed no statistically significant difference with MRI results (p = 0.05), similar to the scaphoid compression test (p = 0.05). For anatomical snuff box tenderness compared to MRI, a statistically significant
difference was observed with p = 0.000. For sensitivity and specificity, this was highest for scaphoid tubercle
tenderness with 95.23% respectively 74.07% for clinical examination, followed by tenderness
of the anatomical snuff box and compression with much lower specificity of 29.62%
each.[7]
For diagnostic imaging, we found only 13 studies which included 100 or more patients.
In addition, the majority of studies on this topic were conducted prior to 2010, which
is at risk of being outdated considering the rapid advance of radiographic technology.
In total, one study focused on bone scintigraphy, five studies on CT scan, two studies
on MRI, and one study on US imaging were published after 2010. Regarding CT, it has
been shown that general wrist CT and CT scaphoid sequences (in the corresponding planes)
yielded different sensitivity and specificity, favoring the CT sequence formatting
specifically for the scaphoid. The sensitivity for CT wrist was 33% with a specificity
of 89%, as compared to 67 and 95% for CT scaphoid. For our review, we only included
the CT scaphoid sequences.[25] In recent studies, the interests of investigators focused more on the cone beam
CT.[23]
[24] In contrast, similar findings were found on the different MRI sequences. According
to Larribe et al, MRI contrast-(gadolinium) enhanced images showed highest sensitivity
(83%) and specificity (100%) as compared to unenhanced sequences with 67 and 67%,
respectively, which were statistically significant.[26] However, the impact of the MRI magnitude on the resolution of scaphoid fractures
stays unclear, as different magnetic field strengths have not been investigated yet.
Timing can also play a critical role in the reported accuracy of the radiographic
findings. Kumar et al[65] showed that the sensitivity of MRI within 24 hours after trauma compared to day
10 after initial presentation did not show any difference. However, no other comparable
study could be found investigating the timing and accuracy of imaging. Furthermore,
a major factor on the sensitivity and specificity of scaphoid fracture can be the
experience of the radiologist. For CT scans, the interobserver agreement among four
different radiologists for scaphoid fractures was between 7 and 15% with a kappa value
of 0.51. This brings up the question that scaphoid fracture may be over- or underdiagnosed
because of interobserver viability.[33]
[67]
In addition, the standard website used for CT radiographs evaluation may have a major
impact on the accuracy of scaphoid fracture diagnosis. Mallee et al showed that DICOM
viewer has superior diagnostic performance characteristics than static JPEG images.
Although no differences in specificity, accuracy, and PPV were observed, the sensitivity
and NPV were significantly higher.[68]
Another study assessed the prognostic value of indirect scaphoid fracture signs. Therefore,
the pre- and postoperative radiographic interscaphoid carpal alignment was measured,
using the radiolunate angle, carpal alignment index, scapholunate, and capitolunate
angles. Highest reliability was shown for the radiolunate angle (pre- vs. postoperative
measures 16.4 ± 5.4 vs. 8.1 ± 4.4, p = 0.01) as well as for the carpal alignment index. For the scapholunate and capitolunate
angles, the reliability was less (52.6 ± 8.7 vs. 43.5 ± 8.4, p = 0.04; 15.3 ± 9.4 vs. 9.7 ± 7.3, p = 0.12); however, it could be used as an alternative tool.[69] The carpal indices would only be abnormal in the presence of scaphoid fracture angulation
and/or displacement at the fracture site, in the absence of intracarpal ligamentous
injury.
To receive most information of the CT imaging, we would recommend to use scaphoid
high-resolution CT in the plane of the scaphoid to catch even small subtle fractures.
The timing of the CT scan—early versus delayed imaging—could not be elaborated based
on the literature, and therefore it remains unclear. For evaluation DICOM viewer showed
superior performance and besides direct fracture signs—presence of a radiolucent fracture
line—indirect signs should be used. Therefore, the radiolunate angle as well as carpal
alignment index showed to be the most reliable factors that can be supplemented using
the scapholunate and capitolunate angles.
As societal costs have increased, clinicians have to focus more on the costs and clinical
effectiveness of the individual tools. As MRI, CT scan, and US have become more popular,
bone scintigraphy had not been investigated in recent studies. MRI has been shown
to be superior to conventional radiography, in its ability to detect the scaphoid
fracture and a negative MRI can reduce societal costs of unnecessary immobilization,
since a normal MRI essentially rules out a scaphoid fracture.[70] When comparing CT scan with MRI, there is still no consensus, but it is worth noting
that most studies support the fact that MRI is better able to detect scaphoid fractures.[71] If an MRI shows a scaphoid fracture, a CT scan should probably still be performed
to assess for displacement that, if present, would favor surgical treatment versus
cast immobilization.
Based on our findings, we would recommend following diagnostic algorithm with respect
to diagnostic imaging ([Fig. 2]).
Fig. 2 Diagnostic algorithm for suspected scaphoid fracture. CT, computed tomography; MRI,
magnetic resonance imaging.
Ultrasonography has a lower sensitivity and specificity (81.5 and 77.4%, respectively)
compared to MRI, CT, and bone scintigraphy. Although US is not the most accurate,
it still has the advantage that it is easily accessible, cheap, and fast. However,
this technique is also operator dependent and is not in widespread use for the detection
of scaphoid fractures.
To assess scaphoid union during follow-up, plain X-ray showed a high agreement for
nonunion after 6 months (kappa = 0.816), although only moderate reliability and accuracy
were found for partial and full consolidation (kappa = 0.390 and 0.517). Therefore,
CT scanning is probably the most reliable method of assessing scaphoid union as it
can demonstrate trabecular healing crossing the fracture site.[72]
This systematic review and meta-analysis show that MRI has the highest sensitivity
and specificity for detecting scaphoid fractures. CT and US were shown to be significantly
lower. However, MRI is more expensive and may not be as readily available as CT, thereby
making CT a more pragmatic option for many patients. In comparison to previously published
systematic reviews, six additional articles were included. Newer studies incorporating
new imaging techniques will need to be studied in order to provide a more up-to-date
understanding.
