Clinical tests for Scaphoid fractures
Date First Published:
September 21, 2008
Last Updated:
April 7, 2011
Report by:
Michael Callaghan , ESP (Manchester Royal infirmary)
Search checked by:
Janet Fowler, Manchester Royal infirmary
Three-Part Question:
In [adults with suspected scaphoid fracture] which [is the best clinical test] to [diagnose this injury]
Clinical Scenario:
A 41 year old female presents to the department hours after a FOOSH. She has pain on the radial side of the wrist and over the ASB. You wonder if she has had a fracture of the scaphoid and want to know the best clinical test to help the diagnosis
Search Strategy:
MEDLINE 1966-2/11, CINAHL 1982 2/11, AMED 1985-2/11, SPORTDiscus 1830-2/11, EMBASE 1996-2/11, via the OVID interface. The Cochrane database, December 2009 and PEDro database, December 2009.
Search Details:
Medline, CINAHL, AMED, EMBASE, SPORTSDiscus, Cochrane database: [{(exp scaphoid bone OR exp carpal navicular bone OR scaphoid.mp) AND (fracture.mp) AND (examin$mp OR clinical test.mp)]
LIMIT to human AND English language AND diagnostic sensitivity and specificity.
LIMIT to human AND English language AND diagnostic sensitivity and specificity.
Outcome:
198 papers were retrieved, of which 6 were relevant to the 3 part question. 1 used MR imaging as the reference test and the other 4 used plain radiography, and 1 used a combination of plain radiography and scintigraphy.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures. Waeckerle JF 1987, USA | N = 85 Reference standard: Plain radiograph |
Diagnostic study 1a | 1. Anatomical snuff box (ASB) tenderness | Sensitivity = 100%<br><br> Specificity = 98% <br><br>PPV = 0.97<br><br>NPV = 1 | |
| 2. Resisted supination | Sensitivity = 100%<br><br>Specificity = 98% <br><br>PPV = 0.97<br><br>NPV = 1 | ||||
| 3. Thumb axial compression (AC) | Sensitivity = 97.5%<br><br>Specificity = 97.8% <br><br>PPV = 0.95<br><br>NPV = 0.97 | ||||
| A new clinical test for fracture of the scaphoid. Powell JM ,Lloyd GJ, Rintoul RF. 1988, Canada | N = 73 Reference standard: Plain radiograph |
Diagnostic study 1a |
1. New test: pain in ASB during Pronation + Ulnar deviation | Sensitivity = 100%<br><br>Specificity = 66% <br><br>PPV = 52<br><br>NPV = 100 | Age range not stated. |
| The scaphoid compression test. Chen SC. 1989, UK | N = 52 Reference standard: Plain radiograph |
Retrospective study | 1. Thumb AC | Sensitivity = 70.5%<br><br>Specificity = 91%<br><br>PPV = 0.85<br><br>NPV = 0.70 | Retrospective study of 10-year period. Age range 11-85 yrs. No break down of results by age group. |
| Clinical signs in scaphoid fractures. Waizenegger M, Barton NJ, Davis TR, et al. 1994, UK | N = 52 Reference standard = Plain or scinitgraphy |
Diagnostic study 1a | 1. Kirk-Watson test | Sensitivity = 82%<br><br>Specificity = 31% | Poor description of clinical tests. Mixture of the reference gold standard test. |
| 2. Clamp test | Sensitivity = 26% <br><br>Specificity = 79% | ||||
| 3. ASB tenderness | Sensitivity = 87%<br><br>Specificity = 38% | ||||
| 4. Thumb AC | Sensitivity = 50%<br><br>Specificity = 51% | ||||
| 5. Pronation and UDev | Sensitivity = 83%<br><br>Specificity = 17% | ||||
| 6. Pronation and RDev | Sensitivity = 70%<br><br>Specificity = 31% | ||||
| 7. Resisted supination | Sensitivity = 83%<br><br>Specificity = 38% | ||||
| Combining the clinical signs improves diagnosis of scaphoid fractures Parvizi J, Wayman J, Kelly P, et al. 1998, UK | N = 215 Reference standard: Plain radiograph |
Diagnostic study level 1a | 1. ASB tenderness | Sensitivity = 100%<br><br>Specificity = 19% <br><br>PPV = 0.3 <br><br>NPV = 1 | 38 patients lost to follow up. Age range 6-79 years. No results breakdown by age. |
| 2. Thumb AC | Sensitivity = 100%<br><br>Specificity = 48%<br><br>PPV = 0.4<br><br>NVP = 1 | ||||
| 3. Scaphoid tubercle (ST) tenderness | Sensitivity = 100%<br><br>Specificity = 30%<br><br>PPV = 0.34 4.<br><br>NPV = 1 | ||||
| 4. Loss of thumb ROM | Sensitivity - 66% <br><br>Specificity = 66%<br><br>PPV = 0.41 <br><br>NPV = 0.85 | ||||
| 5. ASB + AC | Sensitivity = 100%<br><br>Specificity = 54%<br><br>PPV = 0.43 <br><br>NVP = 1 | ||||
| 6. ASB + AC + ST | Sensitivity = 100%<br><br>Specificity = 74%<br><br>PPV = 0.58<br><br>NPV = 1 | ||||
| Examination tests predictive of bone injury in patients with clinically suspected occult scaphoid fracture. Unay K, Gokcon B, Ozkan K et al. 2009, Turkey | N = 41 with occult fracture not visible plain film. Reference standard: MR scans |
Diagnostic study 1a | 1. Thumb ABD | Sensitivity = 73%<br><br>Specificity = 50% <br><br>PPV = 0.86 <br><br>NPV = 0.31 | Not stated who performed the clinical tests. Age range 9-50 years. Unclear if radiology images were scored independently. |
| 2. Wrist RDev | Sensitivity = 68%<br><br>Specificity = 33%<br><br>PPV = 0.93<br><br>NPV = 0.08 | ||||
| 3. Thumb AC | Sensitivity = 71%<br><br>Specificity = 35%<br><br>PPV = 0.54 <br><br>NPV = 0.54 | ||||
| 4. Wrist Flexion | Sensitivity = 71%<br><br>Specificity = 50%<br><br>PPV = 0.89<br><br>NPV = 0.23 | ||||
| 5. Wrist Extension | Sensitivity = 72%<br><br>Specificity = 60%<br><br>PPV = 0.93<br><br>NPV = 0.23 | ||||
| 6. Power grip | Sensitivity = 67% <br><br>Specificity = 20%<br><br>PPV = 0.86<br><br>NPV = 0.08 | ||||
| 7. Wrist UDev | Sensitivity = 70% <br><br>Specificity = 36%<br><br>PPV = 0.75<br><br>NPV = 0.31 | ||||
| 8. Wrist Pro | Sensitivity = 79% <br><br>Specificity = 58%<br><br>PPV = 0.82<br><br>NPV = 0.54 | ||||
| 9. Wrist Sup | Sensitivity = 76%<br><br>Specificity = 50%<br><br>PPV = 0.79<br><br>NPV = 0.46 | ||||
| 10. Pinch grip | Sensitivity = 73%<br><br>Specificity = 75%<br><br>PPV = 0.98<br><br>NPV = 0.23 |
Author Commentary:
Studies vary widely in diagnostic values for a variety of tests. Only one study used MR imaging as the gold standard. There is no consensus as to the best clinical test for a scaphoid fracture.
ASB tenderness in all studies gave 100% sensitivity (i.e. if ASB tenderness is absent, then a fracture is highly unlikely). Specificity ranged from high, at 98% (i.e. if ASB tenderness is present then a fracture is likely) to low, at 19% (i.e. if ASB tenderness is present then a fracture is less likely). There is some evidence that a combination of tests (pain on ASB + AC + ST) will give perfect sensitivity and high specificity.
Most clinical tests had higher sensitivity than specificity, which means that a fracture is unlikely to be missed but they will give a high number of false positives.
ASB tenderness in all studies gave 100% sensitivity (i.e. if ASB tenderness is absent, then a fracture is highly unlikely). Specificity ranged from high, at 98% (i.e. if ASB tenderness is present then a fracture is likely) to low, at 19% (i.e. if ASB tenderness is present then a fracture is less likely). There is some evidence that a combination of tests (pain on ASB + AC + ST) will give perfect sensitivity and high specificity.
Most clinical tests had higher sensitivity than specificity, which means that a fracture is unlikely to be missed but they will give a high number of false positives.
Bottom Line:
A combination of clinical tests seems to give the best diagnostic values for a scaphoid fracture.
References:
- Waeckerle JF . A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures.
- Powell JM ,Lloyd GJ, Rintoul RF.. A new clinical test for fracture of the scaphoid.
- Chen SC.. The scaphoid compression test.
- Waizenegger M, Barton NJ, Davis TR, et al.. Clinical signs in scaphoid fractures.
- Parvizi J, Wayman J, Kelly P, et al.. Combining the clinical signs improves diagnosis of scaphoid fractures
- Unay K, Gokcon B, Ozkan K et al.. Examination tests predictive of bone injury in patients with clinically suspected occult scaphoid fracture.