Bone scintigraphy (BS) in diagnosing scaphoid fractures with normal X-ray results
Date First Published:
July 16, 2010
Last Updated:
July 16, 2010
Report by:
Zinnirah Zainodin, Medical student (University of Manchester)
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
Search Details:
[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.]
Limit to English language AND humans AND all adult (19 plus years).
AND
[exp Radionuclide Imaging OR bone scintigraphy$.mp. OR bone scan$.mp.]
Outcome:
66 papers were identified in Medline, only five papers were identified relevant to the three-part question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Bone scintigraphy in the management of X-ray-negative potential scaphoid fractures. Wilson AW, Kurer MHJ, Peggington JL, Grant DS and Kirk CCJ. 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. |
| The utility of a bone scan in a diagnosis of clinical scaphoid fracture. 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) | ||||
| Fifteen minutes bone scintigraphy in patients with clinically suspected scaphoid fracture and normal x-rays. Bayer LR, Widding A, Diemer H 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. |
| Outcome of routine bone scintigraphy in suspected scaphoid fractures Beeres FJP, Hogervorst M, den Hollander P, Rhemrev S 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. |
| A prospective comparison for suspected scaphoid fractures: Bone scintigraphy versus clinical Outcome Beeres FJP, Hogervorst M, Rhemrev SJ, den Hollander P, Jukema GN. 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% |
Author Commentary:
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
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:
- Wilson AW, Kurer MHJ, Peggington JL, Grant DS and Kirk CCJ.. Bone scintigraphy in the management of X-ray-negative potential scaphoid fractures.
- Murphy D, Eisenhauer M. The utility of a bone scan in a diagnosis of clinical scaphoid fracture.
- Bayer LR, Widding A, Diemer H. Fifteen minutes bone scintigraphy in patients with clinically suspected scaphoid fracture and normal x-rays.
- Beeres FJP, Hogervorst M, den Hollander P, Rhemrev S. Outcome of routine bone scintigraphy in suspected scaphoid fractures
- Beeres FJP, Hogervorst M, Rhemrev SJ, den Hollander P, Jukema GN.. A prospective comparison for suspected scaphoid fractures: Bone scintigraphy versus clinical Outcome