Riding the Waves! nCan ultrasound improve the early diagnosis of occult scaphoid fractures? n
Date First Published:
May 19, 2020
Last Updated:
May 19, 2020
Report by:
Michael Bennett, Consultant (CHI @Tallaght)
Search checked by:
Michael Bennett, CHI @Tallaght
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)
S1tscaphoidtttt
S2t“scaphoid bone”ttt
S3t(MM “scaphoid bone/IN”)tt
S4tS1 OR S2 OR S3ttt
S5tultrasonograph*ttt
S6tultrasoundtttt
S7t(MM “ultrasonography”)tt
S8tultrasound OR ultrasonography* OR sonograph*ttt
S9tS5 OR S6 OR S7 OR S8tt
S10tS4 AND S9
tttt
Search strategy for EMBASE
#1t“scaphoid”tttt
#2t“scaphoid bone”ttt
#3t“scaphoid bone” AND “fracture”t
#4tultrasoundtttt
#5tultrasonograph*ttt
#6tsonograph*tttt
#7t#5 OR #6 OR #7ttt
#8t#1 OR #2 OR #3ttt
#9t#7 AND #8
Search strategy for Google Scholar
#1tscaphoidtttt
#2t“scaphoid bone”ttt
#3t“scaphoid bone” AND “fracture”t
#4t“scaphoid bone” AND “fracture” AND “ultrasound”tt
Search Strategy for Cochrane Library
#1tscaphoidtttt
#2tscaphoid bonettt
#3tscaphoid bone AND fracturet
#4tscaphoid AND ultrasoundtt
t
tttt
S1tscaphoidtttt
S2t“scaphoid bone”ttt
S3t(MM “scaphoid bone/IN”)tt
S4tS1 OR S2 OR S3ttt
S5tultrasonograph*ttt
S6tultrasoundtttt
S7t(MM “ultrasonography”)tt
S8tultrasound OR ultrasonography* OR sonograph*ttt
S9tS5 OR S6 OR S7 OR S8tt
S10tS4 AND S9
tttt
Search strategy for EMBASE
#1t“scaphoid”tttt
#2t“scaphoid bone”ttt
#3t“scaphoid bone” AND “fracture”t
#4tultrasoundtttt
#5tultrasonograph*ttt
#6tsonograph*tttt
#7t#5 OR #6 OR #7ttt
#8t#1 OR #2 OR #3ttt
#9t#7 AND #8
Search strategy for Google Scholar
#1tscaphoidtttt
#2t“scaphoid bone”ttt
#3t“scaphoid bone” AND “fracture”t
#4t“scaphoid bone” AND “fracture” AND “ultrasound”tt
Search Strategy for Cochrane Library
#1tscaphoidtttt
#2tscaphoid bonettt
#3tscaphoid bone AND fracturet
#4tscaphoid AND ultrasoundtt
t
tttt
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)
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):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Scaphoid fracture: a new method of assessment Hodgkinson DW, Nicholson DA, Stewart G, Sheridan M, Hughes P 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 |
| Ultrasound for diagnosis of scaphoid fractures Munk B, Bolvig L, Krøner K, Christiansen T, Borris L, Boe S 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 |
| Scaphoid Fractures: Evaluation with High-Spatial-Resolution US—Initial Results Herneth AM, Siegmeth A, Bader TR, Ba-Ssalamah A, Lechner G, Metz VM, 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 |
| Occult fractures of the waist of the scaphoid: early diagnosis by high-spatial-resolution sonography Hauger O, Bonnefoy O, Moinard M, Bersani D, Diard F. 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 |
| Ultrasound for the early diagnosis of clinically suspected scaphoid fracture Senall JA, Failla JM, Bouffard JA, van Holsbeeck M 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 |
| Diagnosis of occult scaphoid fracture with high-spatial-resolution sonography: a prospective blind study Fusetti C, Poletti PA, Pradel PH, Garavaglia G, Platon A, Della Santa DR, et al 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 |
| Assessment of Recent Occult Scaphoid Fractures by High Resolution Sonography Sayed M, El-Beblawy MA, Gad AA 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 |
| Occult fractures of the scaphoid: the role of ultrasonography in the emergency department Platon A, Poletti P-A, Aaken J, Fusetti C, Della Santa D, Beaulieu J-Y, et al 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 |
| The role of bedside ultrasonography for occult scaphoid fractures in the emergency department Yildirim A, Unluer EE, Vandenberk N, Karagoz 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 |
Author Commentary:
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 .
Bottom Line:
In particular, there was no evidence for ED-performed ultrasound in diagnosing SF.
References:
- Hodgkinson DW, Nicholson DA, Stewart G, Sheridan M, Hughes P. Scaphoid fracture: a new method of assessment
- Munk B, Bolvig L, Krøner K, Christiansen T, Borris L, Boe S. Ultrasound for diagnosis of scaphoid fractures
- 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
- 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
- Senall JA, Failla JM, Bouffard JA, van Holsbeeck M. Ultrasound for the early diagnosis of clinically suspected scaphoid fracture
- 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
- Sayed M, El-Beblawy MA, Gad AA. Assessment of Recent Occult Scaphoid Fractures by High Resolution Sonography
- 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
- Yildirim A, Unluer EE, Vandenberk N, Karagoz. The role of bedside ultrasonography for occult scaphoid fractures in the emergency department