Clinical Orthopaedics and Related Research®

, Volume 468, Issue 3, pp 723–734 | Cite as

Diagnosing Suspected Scaphoid Fractures: A Systematic Review and Meta-analysis

  • Zhong-Gang Yin
  • Jian-Bing Zhang
  • Shi-Lian Kan
  • Xiao-Gang Wang
Clinical Research


Imaging protocols for suspected scaphoid fractures among investigators and hospitals are markedly inconsistent. We performed a systematic review and meta-analysis to assess and compare the diagnostic performance of bone scintigraphy, MRI, and CT for diagnosing suspected scaphoid fractures. Twenty-six studies were included. Sensitivity, specificity, and diagnostic odds ratio were pooled separately and summary receiver operating characteristic curves were fitted for each modality. Meta-regression analyses were performed to compare these modalities. We obtained likelihood ratios derived from the pooled sensitivity and specificity and, using Bayes’ theorem, calculated the posttest probability by application of the tests. The pooled sensitivity, specificity, natural logarithm of the diagnostic odds ratio, and the positive and negative likelihood ratios were, respectively, 97%, 89%, 4.78, 8.82, and 0.03 for bone scintigraphy; 96%, 99%, 6.60, 96, and 0.04 for MRI; and 93%, 99%, 6.11, 93, and 0.07 for CT. Bone scintigraphy and MRI have equally high sensitivity and high diagnostic value for excluding scaphoid fracture; however, MRI is more specific and better for confirming scaphoid fracture. We believe additional studies are needed to assess diagnostic performance of CT, especially paired design studies or randomized controlled trials to compare CT with MRI or bone scintigraphy.

Level of Evidence: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.


Diagnostic Performance Bone Scintigraphy Negative Likelihood Ratio Index Test Reference Test 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Ma Ning for literature collection.


  1. 1.
    Adey L, Souer JS, Lozano-Calderon S, Palmer W, Lee SG, Ring D. Computed tomography of suspected scaphoid fractures. J Hand Surg Am. 2007;32:61–66.CrossRefPubMedGoogle Scholar
  2. 2.
    Akdemir UO, Atasever T, Sipahioğlu S, Türkölmez S, Kazimoğlu C, Sener E. Value of bone scintigraphy in patients with carpal trauma. Ann Nucl Med. 2004;18:495–499.CrossRefPubMedGoogle Scholar
  3. 3.
    Amrami KK. Radiology corner: diagnosing radiographically occult scaphoid fractures—what’s the best second test? J Am Soc Surg Hand. 2005;5:134–138.CrossRefGoogle Scholar
  4. 4.
    Beeres FJ, Rhemrev SJ, den Hollander P, Kingma LM, Meylaerts SA, le Cessie S, Bartlema KA, Hamming JF, Hogervorst M. Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures. J Bone Joint Surg Br. 2008;90:1205–1209.CrossRefPubMedGoogle Scholar
  5. 5.
    Begg CB. Systematic reviews of diagnostic accuracy studies require study by study examination: first for heterogeneity, and then for sources of heterogeneity. J Clin Epidemiol. 2005;58:865–866.CrossRefPubMedGoogle Scholar
  6. 6.
    Breederveld RS, Tuinebreijer WE. Investigation of computed tomographic scan concurrent criterion validity in doubtful scaphoid fracture of the wrist. J Trauma. 2004;57:851–854.CrossRefPubMedGoogle Scholar
  7. 7.
    Breitenseher MJ, Metz VM, Gilula LA, Gaebler C, Kukla C, Fleischmann D, Imhof H, Trattnig S. Radiographically occult scaphoid fractures: value of MR imaging in detection. Radiology. 1997;203:245–250.PubMedGoogle Scholar
  8. 8.
    Breitenseher MJ, Trattnig S, Gäbler C, Happel B, Bankier A, Kukla C, Rand T, Imhof H. [MRI in radiologically occult scaphoid fractures: initial experiences with 1.0 Tesla (whole body-middle field equipment) versus 0.2 Tesla (dedicated low-field equipment)] [in German]. Radiologe. 1997;37:812–818.CrossRefPubMedGoogle Scholar
  9. 9.
    Bretlau T, Christensen OM, Edström P, Thomsen HS, Lausten GS. Diagnosis of scaphoid fracture and dedicated extremity MRI. Acta Orthop Scand. 1999;70:504–508.PubMedGoogle Scholar
  10. 10.
    Brismar J. Skeletal scintigraphy of the wrist in suggested scaphoid fracture. Acta Radiol. 1988;29:101–107.PubMedGoogle Scholar
  11. 11.
    Brydie A, Raby N. Early MRI in the management of clinical scaphoid fracture. Br J Radiol. 2003;76:296–300.CrossRefPubMedGoogle Scholar
  12. 12.
    Cnossen JS, Vollebregt KC, de Vrieze N, ter Riet G, Mol BW, Franx A, Khan KS, vam der Post JA. Accuracy of mean arterial pressure and blood pressure measurements in predicting pre-eclampsia: systematic review and meta-analysis. BMJ. 2008;336:1117–1120.CrossRefPubMedGoogle Scholar
  13. 13.
    Cooney WP 3rd. Scaphoid fractures: current treatments and techniques. Instr Course Lect. 2003;52:197–208.PubMedGoogle Scholar
  14. 14.
    Cruickshank J, Meakin A, Breadmore R, Mitchell D, Pincus S, Hughes T, Bently B, Harris M, Vo A. Early computerized tomography accurately determines the presence or absence of scaphoid and other fractures. Emerg Med Australas. 2007;19:223–228.CrossRefPubMedGoogle Scholar
  15. 15.
    Deeks JJ, Altman DG. Diagnostic tests 4: likelihood ratios. BMJ. 2004;329:168–169.CrossRefPubMedGoogle Scholar
  16. 16.
    De Vries SO, Hunink MG, Polak JF. Summary receiver operating characteristic curves as a technique for meta-analysis of the diagnostic performance of duplex ultrasonography in peripheral arterial disease. Acad Radiol. 1996;3:361–369.CrossRefPubMedGoogle Scholar
  17. 17.
    Dinnes J, Deeks J, Kirby J, Roderick P. A methodological review of how heterogeneity has been examined in systematic reviews of diagnostic test accuracy. Health Technol Assess. 2005;9:1–113, iii.Google Scholar
  18. 18.
    Foex B, Speake P, Body R. Best evidence topic report: magnetic resonance imaging or bone scintigraphy in the diagnosis of plain x ray occult scaphoid fractures. Emerg Med J. 2005;22:434–435.CrossRefPubMedGoogle Scholar
  19. 19.
    Fowler C, Sullivan B, Williams LA, McCarthy G, Savage R, Palmer A. A comparison of bone scintigraphy and MRI in the early diagnosis of the occult scaphoid waist fracture. Skeletal Radiol. 1998;27:683–687.CrossRefPubMedGoogle Scholar
  20. 20.
    Fusetti C, Poletti PA, Pradel PH, Garavaglia G, Platon A, Della Santa DR, Bianchi S. Diagnosis of occult scaphoid fracture with high-spatial-resolution sonography: a prospective blind study. J Trauma. 2005;59:677–681.PubMedGoogle Scholar
  21. 21.
    Gäbler C, Kukla C, Breitenseher MJ, Trattnig S, Vécsei V. Diagnosis of occult scaphoid fractures and other wrist injuries: are repeated clinical examinations and plain radiographs still state of the art? Langenbecks Arch Surg. 2001;386:150–154.CrossRefPubMedGoogle Scholar
  22. 22.
    Galbraith RF. A note on graphical presentation of estimated odds ratios from several clinical trials. Stat Med. 1988;7:889–894.CrossRefPubMedGoogle Scholar
  23. 23.
    Groves AM, Cheow HK, Balan KK, Bearcroft PW, Dixon AK. 16 detector multislice CT versus skeletal scintigraphy in the diagnosis of wrist fractures: value of quantification of 99Tcm-MDP uptake. Br J Radiol. 2005;78:791–795.CrossRefPubMedGoogle Scholar
  24. 24.
    Groves AM, Kayani I, Syed R, Hutton BF, Bearcroft PP, Dixon AK, Ell PJ. An international survey of hospital practice in the imaging of acute scaphoid trauma. AJR Am J Roentgenol. 2006;187:1453–1456.CrossRefPubMedGoogle Scholar
  25. 25.
    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. AJR Am J Roentgenol. 2002;178:1239–1245.PubMedGoogle Scholar
  26. 26.
    Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–560.CrossRefPubMedGoogle Scholar
  27. 27.
    Hunter JC, Escobedo EM, Wilson AJ, Hanel DP, Zink-Brody GC, Mann FA. MR imaging of clinically suspected scaphoid fractures. AJR Am J Roentgenol. 1997;168:1287–1293.PubMedGoogle Scholar
  28. 28.
    Irwig L, Macaskill P, Glasziou P, Fahey M. Meta-analytic methods for diagnostic test accuracy. J Clin Epidemiol. 1995;48:119–130; discussion 131–132.CrossRefPubMedGoogle Scholar
  29. 29.
    Jenkins PJ, Slade K, Huntley JS, Robinson CM. A comparative analysis of the accuracy, diagnostic uncertainty and cost of imaging modalities in suspected scaphoid fractures. Injury. 2008;39:768–774.CrossRefPubMedGoogle Scholar
  30. 30.
    Kitsis C, Taylor M, Chandey J, Smith R, Latham J, Turner S, Wade P. Imaging the problem scaphoid. Injury. 1998;29:515–520.CrossRefPubMedGoogle Scholar
  31. 31.
    Kukla C, Gaebler C, Breitenseher MJ, Trattnig S, Vécsei V. [Prospective comparison of MRI vs. direct magnification radiography in occult fractures of the scaphoid bone] [in German]. Unfallchirurg. 1998;101:32–36.CrossRefPubMedGoogle Scholar
  32. 32.
    Kumar S, O’Connor A, Despois M, Galloway H. Use of early magnetic resonance imaging in the diagnosis of occult scaphoid fractures: the CAST Study (Canberra Area Scaphoid Trial). N Z Med J. 2005;118:U1296.PubMedGoogle Scholar
  33. 33.
    Lindequist S, Houshian S, Rosbach SB, Riegels-Nielsen P. [MRI scanning in suspected fractures of the scaphoid bone] [in Danish]. Ugeskr Laeger. 1998;160:7438–7441.PubMedGoogle Scholar
  34. 34.
    Memarsadeghi M, Breitenseher MJ, Schaefer-Prokop C, Weber M, Aldrian S, Gäbler C, Prokop M. Occult scaphoid fractures: comparison of multidetector CT and MR imaging—initial experience. Radiology. 2006;240:169–176.CrossRefPubMedGoogle Scholar
  35. 35.
    Mills EJ, Nachega JB, Buchan I, Orbinski J, Attaran A, Singh S, Rachlis B, Wu P, Cooper C, Thabane L, Wilson K, Guyatt GH, Bangsberg DR. Adherence to antiretroviral therapy in Sub-Saharan Africa and North America: a meta-analysis. JAMA. 2006;296:679–690.CrossRefPubMedGoogle Scholar
  36. 36.
    Moses LE, Shapiro D, Littenberg B. Combining independent studies of a diagnostic test into a summary ROC curve: data-analytic approaches and some additional considerations. Stat Med. 1993;12:1293–1316.PubMedGoogle Scholar
  37. 37.
    Murphy DG, Eisenhauer MA, Powe J, Pavlofsky W. Can a day 4 bone scan accurately determine the presence or absence of scaphoid fracture? Ann Emerg Med. 1995;26:434–438.CrossRefPubMedGoogle Scholar
  38. 38.
    Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. Br J Anaesth. 2007;98:302–316.CrossRefPubMedGoogle Scholar
  39. 39.
    Nielsen PT, Hedeboe J, Thommesen P. Bone scintigraphy in the evaluation of fracture of the carpal scaphoid bone. Acta Orthop Scand. 1983;54:303–306.PubMedCrossRefGoogle Scholar
  40. 40.
    Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004;70:879–884.PubMedGoogle Scholar
  41. 41.
    Plancher KD. Methods of imaging the scaphoid. Hand Clin. 2001;17:703–721.PubMedGoogle Scholar
  42. 42.
    Ring D, Lozano-Calderón S. Imaging for suspected scaphoid fracture. J Hand Surg Am. 2008;33:954–957.CrossRefPubMedGoogle Scholar
  43. 43.
    Rolfe EB, Garvie NW, Khan MA, Ackery DM. Isotope bone imaging in suspected scaphoid trauma. Br J Radiol. 1981;54:762–767.CrossRefPubMedGoogle Scholar
  44. 44.
    Senall JA, Failla JM, Bouffard JA, van Holsbeeck M. Ultrasound for the early diagnosis of clinically suspected scaphoid fracture. J Hand Surg Am. 2004;29:400–405.CrossRefPubMedGoogle Scholar
  45. 45.
    Song F, Khan KS, Dinnes J, Sutton AJ. Asymmetric funnel plots and publication bias in meta-analyses of diagnostic accuracy. Int J Epidemiol. 2002;31:88–95.CrossRefPubMedGoogle Scholar
  46. 46.
    Steinmann SP, Adams JE. Scaphoid fractures and nonunions: diagnosis and treatment. J Orthop Sci. 2006;11:424–431.CrossRefPubMedGoogle Scholar
  47. 47.
    Stordahl A, Schjøth A, Woxholt G, Fjermeros H. Bone scanning of fractures of the scaphoid. J Hand Surg Br. 1984;9:189–190.CrossRefPubMedGoogle Scholar
  48. 48.
    Thorpe AP, Murray AD, Smith FW, Ferguson J. Clinically suspected scaphoid fracture: a comparison of magnetic resonance imaging and bone scintigraphy. Br J Radiol. 1996;69:109–113.CrossRefPubMedGoogle Scholar
  49. 49.
    Tiel-van Buul MM, Roolker W, Broekhuizen AH, Van Beek EJ. The diagnostic management of suspected scaphoid fracture. Injury. 1997;28:1–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Tiel-van Buul MM, van Beek EJ, Broekhuizen AH, Bakker AJ, Bos KE, van Royen EA. Radiography and scintigraphy of suspected scaphoid fracture: a long-term study in 160 patients. J Bone Joint Surg Br. 1993;75:61–65.PubMedGoogle Scholar
  51. 51.
    Ty JM, Lozano-Calderon S, Ring D. Computed tomography for triage of suspected scaphoid fractures. Hand (NY). 2008;3:155–158.Google Scholar
  52. 52.
    Waizenegger M, Wastie ML, Barton NJ, Davis TR. Scintigraphy in the evaluation of the “clinical” scaphoid fracture. J Hand Surg Br. 1994;19:750–753.CrossRefPubMedGoogle Scholar
  53. 53.
    Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol. 2003;3:25. Available at:
  54. 54.
    Wilson AW, Kurer MH, Peggington JL, Grant DS, Kirk CC. Bone scintigraphy in the management of X-ray-negative potential scaphoid fractures. Arch Emerg Med. 1986;3:235–242.PubMedGoogle Scholar
  55. 55.
    You JS, Chung SP, Chung HS, Park IC, Lee HS, Kim SH. The usefulness of CT for patients with carpal bone fractures in the emergency department. Emerg Med J. 2007;24:248–250.CrossRefPubMedGoogle Scholar
  56. 56.
    Zwinderman AH, Bossuyt PM. We should not pool diagnostic likelihood ratios in systematic reviews. Stat Med. 2008;27:687–697.CrossRefPubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2009

Authors and Affiliations

  • Zhong-Gang Yin
    • 1
  • Jian-Bing Zhang
    • 1
  • Shi-Lian Kan
    • 1
  • Xiao-Gang Wang
    • 1
  1. 1.Department of Hand and MicrosurgeryTianjin HospitalTianjinChina

Personalised recommendations