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Three Part Question

In [adult patients with a suspected scaphoid fracture], is [bone scintigraphy (BS)] reliable to [diagnose a fracture in an initially negative X-ray result]?

Clinical Scenario

A 25-year-old right-handed carpenter came to the Emergency Department (ED) with a recent history of a fall onto his outstretched hand. He complained of pain in the wrist and some tenderness was reported in the anatomical snuffbox. The subsequent X-ray showed no abnormality. Should the patient undergo another investigation, such as an MRI, there and then?

Search Strategy

Ovid MEDLINE(R) 1950 to June Week 4 2010
[exp Scaphoid Bone OR exp Carpal Bones OR scaphoid$.mp. OR exp Fractures, Bone OR fracture$.mp]
Limit to English language AND humans AND all adult (19 plus years).
AND
[exp Radionuclide Imaging OR bone scintigraphy$.mp. OR bone scan$.mp.]

Search Outcome

66 papers were identified in Medline, only five papers were identified relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wilson AW et al. 1986. England	111 patients (73 male, 38 women), mean age: 36 years old Presented to ED with suspected scaphoid fracture but negative initial x-ray	Diagnostic study, Diagnostic cohort study	Fractures seen on BS	29-scaphoid fracture, 13-distal radius, 38-other carpal bones, 15-phalanges, 11-increased generalised uptake, 5-normal	Publication bias not mentioned. Statistical analysis of the result was not discussed. Sensitivity or specificity was not included.
Murphy D, Eisenhauer M. 1994. Canada	54 patients (39 males, 15 females), mean age: 32.3 years old Presented to ED with suspected scaphoid fracture but negative initial x-ray	Retrospective study, Diagnostic cohort study	Scaphoid fracture on radiography 10-14 days post-injury	2-fractures on radiography, 37-negative radiography and no anatomical snuffbox tenderness – discharged, 15-negative x-ray but positive clinical exam – undergo BS	Statistical analysis was not included. Small samples size. Publication bias not mentioned. Sensitivity or specificity was not included
			BS findings	7-negative BS 8-positive BS (6-scaphoid fracture, 2-other fracture)
Bayer LR et al. 2000 Denmark	40 patients (14 males, 26 females), mean age: 32 Presented to ED with suspected scaphoid fracture but negative initial x-ray	Retrospective study, Diagnostic cohort study	Fractures seen on BS	8-scaphoid fractures, 5-distal radius, 8-other carpal bones fracture, 5-diffuse uptake, 17-normal	Statistical analysis was not included. Small samples size. Publication bias not mentioned. Sensitivity or specificity was not included.
Beeres FJP et al. 2005 The Netherlands	56 patients (36 male, 20 female) Mean age: 38 years old Presented to ED with suspected scaphoid fracture but negative initial x-ray	Retrospective study, Diagnostic cohort study	Fractures seen on BS images	15-Scaphoid fracture, 11-distal radius fracture, 9-other carpal fracture, 3-metacarpal fracture, 7-wrist contusion, 11-normal	Small samples size. Publication bias not mentioned. Statistical analysis of the result was not discussed. Sensitivity or specificity was not included.
Beeres FJP et al. 2007 The Netherlands	50 patients (29 male, 21 female) Mean age: 42 years old. Presented to ED with suspected scaphoid fracture but negative initial x-ray	Prospective study, Blinded, Diagnostic cohort study	Fractures seen on BS images	14-scaphoid fracture, 2-Scaphoid and distal radius, 20-Other fractures, 14-Normal	Small samples size. Publication bias not mentioned. Statistical analysis of the result was not discussed. Another outcome i.e. physical examination findings was not clearly stated.
			BS	Sensitivity: 92% Specificity: 87%

Comment(s)

BS has shown evidence of significant reliability for detecting scaphoid fractures in negative initial X-ray findings. BS works principally by detecting the focal uptake of the radionuclide by the osteoblast activity, which is optimum at 3-5 days post-injury, therefore during this period BS imaging will be most sensitive. Increased focal activity may be because of fracture, neoplasm or other soft tissue injuries; therefore careful interpretation and review need to be taken into account

Clinical Bottom Line

BS may be used as a second-line investigation after 3-5 days post-injury in patients with wrist trauma but a negative initial X-ray investigation. However, safety and cost-effectiveness have not been established and more studies are needed to answer these questions.

References

1. Wilson AW, Kurer MHJ, Peggington JL, Grant DS and Kirk CCJ. Bone scintigraphy in the management of X-ray-negative potential scaphoid fractures. Archives of Emergency Medicine. 1986; 3: 235-42
2. Murphy D, Eisenhauer M The utility of a bone scan in a diagnosis of clinical scaphoid fracture. The Journal of Emergency Medicine 1994; 5 (12): 709-12.
3. Bayer LR, Widding A, Diemer H Fifteen minutes bone scintigraphy in patients with clinically suspected scaphoid fracture and normal x-rays. Injury, Int. J. Care Injured 2000; 31:243-8.
4. Beeres FJP, Hogervorst M, den Hollander P, Rhemrev S Outcome of routine bone scintigraphy in suspected scaphoid fractures Injury, Int. J. Care Injured. 2005; 36: 1233-6.
5. Beeres FJP, Hogervorst M, Rhemrev SJ, den Hollander P, Jukema GN. A prospective comparison for suspected scaphoid fractures: Bone scintigraphy versus clinical Outcome Injury, Int. J. Care Injured 2007; 38: 769-74