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Clinical tests for Scaphoid fractures

Three Part Question

In [adults with suspected scaphoid fracture] which [is the best clinical test] to [diagnose this injury]

Clinical Scenario

A 41 year old female presents to the department hours after a FOOSH. She has pain on the radial side of the wrist and over the ASB. You wonder if she has had a fracture of the scaphoid and want to know the best clinical test to help the diagnosis

Search Strategy

MEDLINE 1966-2/11, CINAHL 1982 2/11, AMED 1985-2/11, SPORTDiscus 1830-2/11, EMBASE 1996-2/11, via the OVID interface. The Cochrane database, December 2009 and PEDro database, December 2009.

Medline, CINAHL, AMED, EMBASE, SPORTSDiscus, Cochrane database: [{(exp scaphoid bone OR exp carpal navicular bone OR scaphoid.mp) AND (fracture.mp) AND (examin$mp OR clinical test.mp)]
LIMIT to human AND English language AND diagnostic sensitivity and specificity.

Search Outcome

198 papers were retrieved, of which 6 were relevant to the 3 part question. 1 used MR imaging as the reference test and the other 4 used plain radiography, and 1 used a combination of plain radiography and scintigraphy.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Waeckerle et al,
1987,
USA
N = 85 Reference standard: Plain radiograph Diagnostic study 1a1. Anatomical snuff box (ASB) tendernessSensitivity = 100%

Specificity = 98%

PPV = 0.97

NPV = 1
2. Resisted supinationSensitivity = 100%

Specificity = 98%

PPV = 0.97

NPV = 1
3. Thumb axial compression (AC)Sensitivity = 97.5%

Specificity = 97.8%

PPV = 0.95

NPV = 0.97
Powell et al,
1988,
Canada
N = 73 Reference standard: Plain radiograph Diagnostic study 1a 1. New test: pain in ASB during Pronation + Ulnar deviationSensitivity = 100%

Specificity = 66%

PPV = 52

NPV = 100
Age range not stated.
Chen,
1989,
UK
N = 52 Reference standard: Plain radiograph Retrospective study1. Thumb ACSensitivity = 70.5%

Specificity = 91%

PPV = 0.85

NPV = 0.70
Retrospective study of 10-year period. Age range 11-85 yrs. No break down of results by age group.
Waizenegger,
1994,
UK
N = 52 Reference standard = Plain or scinitgraphy Diagnostic study 1a1. Kirk-Watson testSensitivity = 82%

Specificity = 31%
Poor description of clinical tests. Mixture of the reference gold standard test.
2. Clamp testSensitivity = 26%

Specificity = 79%
3. ASB tendernessSensitivity = 87%

Specificity = 38%
4. Thumb ACSensitivity = 50%

Specificity = 51%
5. Pronation and UDevSensitivity = 83%

Specificity = 17%
6. Pronation and RDevSensitivity = 70%

Specificity = 31%
7. Resisted supinationSensitivity = 83%

Specificity = 38%
Parvizi et al,
1998,
UK
N = 215 Reference standard: Plain radiograph Diagnostic study level 1a1. ASB tendernessSensitivity = 100%

Specificity = 19%

PPV = 0.3

NPV = 1
38 patients lost to follow up. Age range 6-79 years. No results breakdown by age.
2. Thumb ACSensitivity = 100%

Specificity = 48%

PPV = 0.4

NVP = 1
3. Scaphoid tubercle (ST) tendernessSensitivity = 100%

Specificity = 30%

PPV = 0.34 4.

NPV = 1
4. Loss of thumb ROMSensitivity - 66%

Specificity = 66%

PPV = 0.41

NPV = 0.85
5. ASB + ACSensitivity = 100%

Specificity = 54%

PPV = 0.43

NVP = 1
6. ASB + AC + STSensitivity = 100%

Specificity = 74%

PPV = 0.58

NPV = 1
Unay et al,
2009,
Turkey
N = 41 with occult fracture not visible plain film. Reference standard: MR scans Diagnostic study 1a1. Thumb ABDSensitivity = 73%

Specificity = 50%

PPV = 0.86

NPV = 0.31
Not stated who performed the clinical tests. Age range 9-50 years. Unclear if radiology images were scored independently.
2. Wrist RDevSensitivity = 68%

Specificity = 33%

PPV = 0.93

NPV = 0.08
3. Thumb ACSensitivity = 71%

Specificity = 35%

PPV = 0.54

NPV = 0.54
4. Wrist FlexionSensitivity = 71%

Specificity = 50%

PPV = 0.89

NPV = 0.23
5. Wrist ExtensionSensitivity = 72%

Specificity = 60%

PPV = 0.93

NPV = 0.23
6. Power gripSensitivity = 67%

Specificity = 20%

PPV = 0.86

NPV = 0.08
7. Wrist UDevSensitivity = 70%

Specificity = 36%

PPV = 0.75

NPV = 0.31
8. Wrist ProSensitivity = 79%

Specificity = 58%

PPV = 0.82

NPV = 0.54
9. Wrist SupSensitivity = 76%

Specificity = 50%

PPV = 0.79

NPV = 0.46
10. Pinch gripSensitivity = 73%

Specificity = 75%

PPV = 0.98

NPV = 0.23

Comment(s)

Studies vary widely in diagnostic values for a variety of tests. Only one study used MR imaging as the gold standard. There is no consensus as to the best clinical test for a scaphoid fracture. ASB tenderness in all studies gave 100% sensitivity (i.e. if ASB tenderness is absent, then a fracture is highly unlikely). Specificity ranged from high, at 98% (i.e. if ASB tenderness is present then a fracture is likely) to low, at 19% (i.e. if ASB tenderness is present then a fracture is less likely). There is some evidence that a combination of tests (pain on ASB + AC + ST) will give perfect sensitivity and high specificity. Most clinical tests had higher sensitivity than specificity, which means that a fracture is unlikely to be missed but they will give a high number of false positives.

Clinical Bottom Line

A combination of clinical tests seems to give the best diagnostic values for a scaphoid fracture.

References

  1. Waeckerle JF A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures. Annals of Emergency Medicine (1987); 16 (7): 733-737.
  2. Powell JM ,Lloyd GJ, Rintoul RF. A new clinical test for fracture of the scaphoid. Canadian Journal of Surgery 1988; 31 (4):237-238.
  3. Chen SC. The scaphoid compression test. Journal of Hand Surgery 1989; 14 (3): 323-325.
  4. Waizenegger M, Barton NJ, Davis TR, et al. Clinical signs in scaphoid fractures. Journal of Hand Surgery 1994; 16 (6): 643-747.
  5. Parvizi J, Wayman J, Kelly P, et al. Combining the clinical signs improves diagnosis of scaphoid fractures Journal of Hand Surgery 1998; 23 (3): 324-327.
  6. Unay K, Gokcon B, Ozkan K et al. Examination tests predictive of bone injury in patients with clinically suspected occult scaphoid fracture. Injury 2009; 40: 1265-1268.