Diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures: a systematic review update

Abstract

Background: The standard diagnostic work-up for hand and wrist fractures consists of history taking, physical examination and imaging if needed, but the supporting evidence for this work-up is limited. The purpose of this study was to systematically examine the diagnostic accuracy of tests for hand and wrist fractures. Methods: A systematic search for relevant studies was performed. Methodological quality was assessed and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted from the eligible studies. Results: Of the 35 eligible studies, two described the diagnostic accuracy of history taking for hand and wrist fractures. Physical examination with or without radiological examination for diagnosing scaphoid fractures (five studies) showed Se, Sp, accuracy, PPV and NPV ranging from 15 to 100%, 13-98%, 55-73%, 14-73% and 75-100%, respectively. Physical examination with radiological examination for diagnosing other carpal bone fractures (one study) showed a Se of 100%, with the exception of the triquetrum (75%). Physical examination for diagnosing phalangeal and metacarpal fractures (one study) showed Se, Sp, accuracy, PPV and NPV ranging from 26 to 55%, 13-89%, 45-76%, 41-77% and 63-75%, respectively. Imaging modalities of scaphoid fractures showed predominantly low values for PPV and the highest values for Sp and NPV (24 studies). Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Ultrasonography (US) and Bone Scintigraphy (BS) were comparable in diagnostic accuracy for diagnosing a scaphoid fracture, with an accuracy ranging from 85 to 100%, 79-100%, 49-100% and 86-97%, respectively. Imaging for metacarpal and finger fractures showed Se, Sp, accuracy, PPV and NPV ranging from 73 to 100%, 78-100%, 70-100%, 79-100% and 70-100%, respectively. Conclusions: Only two studies were found on the diagnostic accuracy of history taking for hand and wrist fractures in the current review. Physical examination was of moderate use for diagnosing a scaphoid fracture and of limited use for diagnosing phalangeal, metacarpal and remaining carpal fractures. MRI, CT and BS were found to be moderately accurate for the definitive diagnosis of clinically suspected carpal fractures.

What is the role of ultrasonography in the early diagnosis of scaphoid fractures?

“…It is essential to understand the clinical findings of scaphoid fractures since it could improve the sensitivity and specificity of US. Diagnosis should be focused on a deep anamnesis and a detailed physical examination, followed by diagnostic images [5,[13][14][15][16].…”

“…Diagnosis is based on clinical examination and images, with wrist radiography being the most commonly used method due to its high availability and low price. Nevertheless, sensitivity and specificity of radiography in the acute phase is not optimal, presenting between 20-25 % of false negatives results, and missing close to 16 % of fractures, for which preventive immobilization, and sometimes additional images such as magnetic resonance imaging (MRI) and computed tomography (CT) are required [1][2][3][4][5]. Consequently, unnecessary wrist immobilization represents a high sanitary cost due to prolonged time off from work [6].…”

“…Consequently, unnecessary wrist immobilization represents a high sanitary cost due to prolonged time off from work [6]. If a scaphoid fracture is left untreated, complications such as non-union, delayed healing, pseudoarthrosis, avascular necrosis, arthrosis, and secondary displacement of the wrist may appear [5,6].…”

“…Currently, there are rising concerns about the use of US for the diagnosis of occult scaphoid fractures because it is an accessible, fast, nonionizing, cost-effective method that may help avoid overtreatment [1,2,5,7].…”

Epidemiology of scaphoid fractures and non-unions: A systematic review

“…When an acute scaphoid fracture is suspected conventional wrist radiographs with supplementary 3-4 special projections of the scaphoid are done. A systematic review of imaging in carpal fractures found that initial radiographs have a 43-70 % sensitivity for detecting an acute scaphoid fracture in adults [11]. Furthermore, a prospective study, where MRI was used as golden standard, showed that conventional radiographs detected 54 % of acute scaphoid fractures in children [6].…”