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Three Part Question

In a [patient presenting with clinical suspicion for a scaphoid fracture and normal radiographs] can [early scaphoid US be a useful diagnostic modality] for [ruling out occult scaphoid fracture's]?

Clinical Scenario

A 22 year old female attends the emergency department after falling on her outstretched hand. On examination she has tenderness over the scaphoid, scaphoid tubercle with pain on axial loading of the thumb as well. Initial plain radiographs are normal. You have recently completed a musculoskeletal ultrasound course and wonder if ultrasound as a modality is useful in the diagnosis of occult scaphoid fractures.

Search Strategy

Search Strategy For Medline & CINAHL (EBSCOhost)
S1 scaphoid
S2 “scaphoid bone”
S3 (MM “scaphoid bone/IN”)
S4 S1 OR S2 OR S3
S5 ultrasonograph*
S6 ultrasound
S7 (MM “ultrasonography”)
S8 ultrasound OR ultrasonography* OR sonograph*
S9 S5 OR S6 OR S7 OR S8
S10 S4 AND S9


Search strategy for EMBASE

#1 “scaphoid”
#2 “scaphoid bone”
#3 “scaphoid bone” AND “fracture”
#4 ultrasound
#5 ultrasonograph*
#6 sonograph*
#7 #5 OR #6 OR #7
#8 #1 OR #2 OR #3
#9 #7 AND #8

Search strategy for Google Scholar

#1 scaphoid
#2 “scaphoid bone”
#3 “scaphoid bone” AND “fracture”
#4 “scaphoid bone” AND “fracture” AND “ultrasound”

Search Strategy for Cochrane Library
#1 scaphoid
#2 scaphoid bone
#3 scaphoid bone AND fracture
#4 scaphoid AND ultrasound

Search Outcome

The search strategy yielded 28 articles relevant for review. CINAHL, EMBASE, and Cochrane databases did not return any unique articles. Eight studies retrieved from EMBASE were duplicates. There were no unpublished trials and grey literature did not return any articles.
Five of the primary studies excluded used US in a therapeutic frequency in an attempt to illicit pain as a marker of possible fracture rather than obtain a diagnostic image.(4-8) Two studies were excluded because they used therapeutic US to determine if US could improve healing of previously diagnosed SFs.(9, 10) A further eleven articles were excluded because they were literature reviews each using only a proportion of articles that were identified by this search.(2, 3, 11-19) Finally, one article was excluded because it was a case report that used US to detect a SF in a solitary paediatric patient.(20)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hodgkinson et al 1993 England	78 patients with unilateral wrist injury and clinical or radiological signs of SF who presented to the ED. US performed by radiologist and a Scaphoid index was calculated from 3 measurements taken from both symptomatic and asymptomatic wrists	Prospective observational diagnostic study.	SF on radiographs	12 patients had SFs Scaphoid index of 30% had Sen 100%, Spec 74%. Scaphoid index 45% had Sen 83%, Spec 82% and scaphoid index 15% had Sen 100%, Spec 56%	Study protocol altered during trial Poor reference standard US criteria for diagnosis did not take into account cortical changes of the scaphoid
Munk et al, 2000 Denmark	58 patients with unilateral wrist injury and clinical suspicion of SF in an outpatient department	Prospective observational diagnostic study Blinded	SF on initial or f/u radiographs at 10-14 days	57 patients included in final analysis 10 SFs on xray 9 fractures on US Accuracy of US 84%, Sen 50%, Spec 91%, PPV 56%, NPV 90% No difference in US techniques	Unclear where patients enrolled from Poor reference standard Despite set criteria for US diagnosis of fracture no comment which elements most predictive for fracture Inter-rater reliability not assessed
Herneth et al 2001 Austria	15 patients with clinical suspicion of SF after trauma OPD setting	Prospective observational diagnostic study	SF on MRI	15 patients 9 (60%) patients had SF on MRI 7 (78%) of the 9 patients had SF on US Accuracy of US was 87%, Sen 78%, Spec 100%, PPV 100%, NPV 75%	Small sample size No inter-rater reliability discussed
Hauger et al, 2002 France	54 patients with clinical suspicion of a SF and normal initial radiographs OPD setting	Prospective multi-centre observational diagnostic study	SF on f/u radiographs at 10-14 days If remained symptomatic had either CT, MRI or bone scan	US detected 6 SFs 5/6 seen on f/u radiographs 1 false positive (confirmed at CT) Sen 100%, Spec 98%, PPV 83%, NPV 100%	Interpretation of reference standard un-blinded to US results Multiple reference standards used ASB tenderness not part of inclusion criteria
Senall et al 2004 USA	18 patients with clinical suspicion of SF and normal initial radiographs OPD setting	Prospective blinded diagnostic study	SF on f/u radiographs	Total 9 patients fractured scaphoid on f/u radiographs US positive 7 (78%) of 9, US 1 false +ve and 2 false –ve Sen 78%, Spec 89%, PPV 88%, NPV 80%	Small sample Poor reference standard Unclear if consecutive sample Axial loading of 1st metacarpal not part of clinical exam No prespecified criteria for SF on US No inter-rater reliability for radiologists
Fusetti C 2005 Switzerland	24 consecutive patients with clinical suspicion of SF and normal radiographs were reviewed in a hand surgery clinic	Prospective observational diagnostic study	SF on CT	A total of 5 patients had SF on CT and all 5 were detected by US Sen 100%, Spec 79%, PPV 56%, and NPV 100%	Small sample Patients initial clinical exam in review clinic US performed by MSK radiologist 8 of 24 patients needed bilateral US examination to elucidate normal anatomy
Sayed et al 2009 Egypt	35 consecutive patients with clinical suspicion of SF and normal radiographs were reviewed in the radiology dept	Prospective observational diagnostic study	SF on radiographs at 14 day f/u	9 total SFs identified 7 (78%) of 9 identified on US Sen 100%, Spec, 88%, PPV 75%, NPV 100%	Small sample Unblinded Poor reference standard 3 patients received further imaging (CT, MRI) to identify fractures
Platon A 2010 Switzerland	62 patients presenting during the day to the ED with clinical suspicion of a SF and normal radiographs	Prospective observational diagnostic study	SF on CT	A total 13 (21%) SFs on CT 12 (92%) fractures detected on US sen 92%, Spec 71%, PPV 46%, NPV 97%	Convenience sample 5 years to recruit sample No attempt to describe inter-rater reliability Hand surgery fellow performed initial examinations
Yildirim et al 2013 Turkey	63 consecutive patients presenting to the ED with clinical suspicion of SF and normal plain radiographs	Prospective observational diagnostic study	SF on MRI	A total of 14 (22%) patients had SF on MRI 12 (86%) of 14 SFs present on US Sen 85.7%, Spec 100%, PPV 100%, NPV 100%, -ve LR 0.14	Convenience sample Investigators unblinded

Comment(s)

Although rare, patients with missed SFs may suffer significant morbidity including non-union of the fracture site, avascular necrosis or osteoarthritis. The poor sensitivity of plain films in the detection of SFs combined with the significant risk of morbidity associated with undiagnosed SFs has led clinicians to investigate numerous diagnostic imaging protocols including the use of MRI, CT and US. While there is encouraging evidence that US may be useful in the diagnosis of occult SFs, unfortunately, this review has found that the current evidence base is fraught with significant methodological flaws resulting in US not currently being sensitive or specific enough to be adopted into my current clinical practice .

Clinical Bottom Line

In particular, there was no evidence for ED-performed ultrasound in diagnosing SF.

References

1. Hodgkinson DW, Nicholson DA, Stewart G, Sheridan M, Hughes P Scaphoid fracture: a new method of assessment Clin Radiol 1993;48(6):398-401
2. Munk B, Bolvig L, Krøner K, Christiansen T, Borris L, Boe S Ultrasound for diagnosis of scaphoid fractures J Hand Surg Br 2000;25(4):369-71
3. Herneth AM, Siegmeth A, Bader TR, Ba-Ssalamah A, Lechner G, Metz VM, et al. Scaphoid Fractures: Evaluation with High-Spatial-Resolution US—Initial Results Radiology 2001;220(1):231-5
4. Hauger O, Bonnefoy O, Moinard M, Bersani D, Diard F. Occult fractures of the waist of the scaphoid: early diagnosis by high-spatial-resolution sonography AJR Am J Roentgenol. 2002;178(5):1239-45. 2002;178(5):1239-45
5. Senall JA, Failla JM, Bouffard JA, van Holsbeeck M Ultrasound for the early diagnosis of clinically suspected scaphoid fracture J Hand Surg Am 2004;29(3):400-5
6. Fusetti C, Poletti PA, Pradel PH, Garavaglia G, Platon A, Della Santa DR, et al Diagnosis of occult scaphoid fracture with high-spatial-resolution sonography: a prospective blind study J Trauma 2005;59(3):677-81
7. Sayed M, El-Beblawy MA, Gad AA Assessment of Recent Occult Scaphoid Fractures by High Resolution Sonography Med J Cairo Univ 2009;77(1):721-7
8. Platon A, Poletti P-A, Aaken J, Fusetti C, Della Santa D, Beaulieu J-Y, et al Occult fractures of the scaphoid: the role of ultrasonography in the emergency department Skeletal Radiol 2011;40(7):869-75
9. Yildirim A, Unluer EE, Vandenberk N, Karagoz The role of bedside ultrasonography for occult scaphoid fractures in the emergency department Ulus Travma Acil errahi Derg 2013;19(3):241-5