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Three Part Question

In [patients with suspected fracture of Scaphoid] is [high resolution spatial Ultrasonography of Scaphoid a useful test] for [early detection of Scaphoid fractures]?

Clinical Scenario

You have seen a 26 year old right hand dominant man with 5 days old suspected fracture of Scaphoid in A&E, he is still tender around his Scaphoid area, and asking for early return to work. You have heard about advances in Ultrasonographic (US) diagnosis of upper and lower limbs pathologies, and wondering if US is a sensitive and specific test for early detection of suspected Scaphoid fractures.

Search Strategy

Searching Medline using National Library of Medicine 1966-05/2003.
Extended search to related articles and using the same strategy in Ovid and Silverplatter Medline and EMBase did not yield further relevant articles.
"Eng[LA] AND Scaphoid fracture AND Ultrasonography"

Search Outcome

Retrieved 11 articles, of which 8 were initially relevant. Review of these 8 articles showed, 6 were not using high spatial Ultrasonography in their studies. 2 papers were relevant to our question which are included below

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hauger et al 2002 France	54 consecutive suspected Scaphoid Fx, normal Xray, within 7 days, 35 M, 19 F, mean age 26, range 10-75	Prospective non –randomised, Diagnostic	Detection of Suspected Scaphoid Fx, using cortical disruption as a diagnostic criterion. Reference gold standard not applied to all.	100% sensitivity, 98% specificity, 83% PPV, 100% NPV	Small sample size, results not compared with gold standard Poor statistical analysis Detection criteria chosen after study conducted.
Herneth et al 2001 Austria	15 Consecutive Acute wrist trauma within 72 hours. 8F, 7M, median age 23.5, range 16-55 years.	Prospective non-randomised Diagnostic	Detection of suspected Scaphoid fracture (cortical discontinuity and periosteal elevation) comparison among	78% sensitivity, 100% specificity,	Small sample size Poor statistical analysis.

Comment(s)

At mean age of 23.5-26 years, high spatial resolution Sonography has 78-100% sensitivity, and 98-100% specificity and Positive Predictive value of 83-100%, and Negative Predictive value of 75-100% in detecting Scaphoid fractures in acute clinical settings. These studies also recognised and validate diagnostic features in detecting Scaphoid fractures using high spatial Sonography. Comparing these to MR sensitivity of 95-100% and specificity of 100% and considering ease of use, cost efficiency, absence of radiation, and speed of examination, Sonography seems to be a reliable and affordable diagnostic alternative in detecting Scaphoid fracture in acute clinical setting where available. Further studies with larger patient population (well designed and addressing the issue of occult Scaphoid fractures exclusively) is needed to establish real value of Sonography in detecting acute Scaphoid fractures.

Clinical Bottom Line

Where available, high spatial resolution Sonography seems to be a sensitive and highly specific diagnostic imaging modality to consider in diagnosis of acute Scaphoid fractures. MR scan remains gold standard in diagnosis of Scaphoid fractures.

References

1. 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. American-Journal-of-Roentgenology. 2002;178(5):1239-1245.
2. Herneth-AM; Siegmeth-A; Bader-TR; Ba-Ssalamah-A; Lechner-G; Metz-VM; Grabenwoeger-F. Scaphoid fractures: Evaluation with high-spatial-resolution US - Initial results. Radiology. 2001;220(1):231-235.