CT scan versus 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 [CT scan is better than bone scintigraphy (BS)] in [diagnosing a fracture with 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 a CT scan 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 Tomography, X-Ray Computed OR computed tomography scan$.mp. OR CT scan$.mp]
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 Tomography, X-Ray Computed OR computed tomography scan$.mp. OR CT scan$.mp]
AND
[exp Radionuclide Imaging OR bone scintigraphy$.mp. OR bone scan$.mp.]
Outcome:
9 papers were identified in Medline, four 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 |
|---|---|---|---|---|---|
| CT of the wrist in suspected scaphoid fracture. Jonsson K, Jonsson A, Sloth M, Kopylov P, Wingstrand H. 1992 Sweden | 10 patients (6 male, 4 female) present at ED With suspected scaphoid fracture but normal initial radiograph |
Diagnostic cohort studies | BS result | 6-scaphoid fracture, 2-increased uptake of scaphoid, 1-trapezium fracture, *1 patient not examined because of pregnancy | Poor data presentation, Publication bias was not stated, Statistical analysis was not included, Small sample size, No sensitivity or specificity of the intervention mentioned. |
| CT result (CT in sagittal projection) | 7-scaphoid fractures, 3-no scaphoid fracture (including 2 patients with increased uptake on BS) | ||||
| Investigation of Computed Tomographic Scan Concurrent Criterion Validity in Doubtful Scaphoid Fracture of the Wrist. Breederveld RS, Tuinebreijer WE 2004 The Netherlands | 29 patients-present at ED with suspected scaphoid fracture but normal initial radiograph | Diagnostic cohort studies | CT scan | sensitivity, specificity, positive and negative predictive values= 100% | Publication bias was not stated, Statistical analysis was not included, Small sample size, Results were not compared with previous studies. Only one nuclear diagnostician interpreting the BS result. |
| BS | Sensitivity 78%, Specificity 90%, Positive predictive values 78%, Negative predictive values 90% | ||||
| False negative 16 detector multislice CT for scaphoid fracture. Groves AM, Cheow HK, Balan KK, Courtney HM, Bearcroft PWP, Dixon AK 2005 England | 1 patient (male) Presented to ED having fallen on outstretched left hand, tender anatomical snuffbox, negative initial radiograph |
Case report | BS vs CT on the day 10 post-injury | scaphoid fracture vs normal | Publication bias was not stated |
| MRI (day 14) | probable scaphoid fracture | ||||
| Radiograph day 42 post-injury | scaphoid fracture | ||||
| 16-MDCT in the Detection of Occult Wrist Fractures: A Comparison with Skeletal Scintigraphy Groves AM, Heok Cheow H, Balan K, Courtney H, Bearcroft P, Dixon A 2005 England | 51 patients (17 male, 34 female), mean age: 40.2 years old. Presented to nuclear medicine department with suspected scaphoid fracture at 10–14 days post injury |
Prospective study, Diagnostic cohort studies |
Scaphoid fractures | 10 BS vs 5 CT (7 patients with +ve BS of scaphoid fracture have normal CT and follow-up radiography at 6 weeks) | Publication bias was not stated. No sensitivity or specificity of the intervention mentioned because no universal gold standard for waist fracture diagnosis. Statistical analysis on the result was mentioned but not included. |
| Radius fractures | 5 BS vs 3 CT | ||||
| Other carpal bones fractures | 8 BS vs 6CT |
Author Commentary:
The different sources of evidence conflict with each other as to whether CT scans are better than BS at diagnosing scaphoid fractures. Studies by Breederveld et al showed that CT scans are superior to BS. A case study by Groves et al claimed that BS is better at detecting scaphoid fractures, while Jonsson et al claimed that CT can be used in place of BS if there are no nuclear medicine facilities. Interestingly, a study by Groves et al found that seven scaphoid fractures detected by BS were negative on CT and the follow-up X-ray.
Bottom Line:
CT scans can possibly be used on patients who present at EDs with a suspected scaphoid fracture, particularly in places with no nuclear medicine facilities (BS). However, not enough evidence is available to claim which one is superior to the other, thus comparisons between CT and BS should be studied further, particularly in terms of cost-effectiveness and safety measures.
References:
- Jonsson K, Jonsson A, Sloth M, Kopylov P, Wingstrand H. . CT of the wrist in suspected scaphoid fracture.
- Breederveld RS, Tuinebreijer WE. Investigation of Computed Tomographic Scan Concurrent Criterion Validity in Doubtful Scaphoid Fracture of the Wrist.
- Groves AM, Cheow HK, Balan KK, Courtney HM, Bearcroft PWP, Dixon AK. False negative 16 detector multislice CT for scaphoid fracture.
- Groves AM, Heok Cheow H, Balan K, Courtney H, Bearcroft P, Dixon A. 16-MDCT in the Detection of Occult Wrist Fractures: A Comparison with Skeletal Scintigraphy