title: Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis.
abstract: OBJECTIVE
  To provide an overview of available clinical evaluation tests for scaphoid fractures and to compare their diagnostic accuracies.
  
  
  METHODS
  PWe performed a systematic review of all studies assessing diagnostic characteristics of clinical evaluation in scaphoid fractures by searching MEDLINE, EMBASE, Cochrane, and CINAHL databases. Only studies on clinical testing prior to radiographic evaluation and with acceptable reference standard for occult fractures were included. Thirteen relevant articles were analyzed that described a total of 25 tests. Diagnostic characteristics of the tests were used to construct contingency tables. If possible, data were pooled and summary receiver operating characteristic curves were fitted.
  
  
  RESULTS
  Anatomic snuff-box tenderness (ASB, 8 studies, 1,164 patients) and longitudinal thumb compression (LTC, 8 studies, 961 patients) had sufficient data for statistical analyses. Sensitivity for ASB ranged from 0.87 to 1.00; for LTC, 0.48 to 1.00. Specificity of ASB ranged from 0.03 to 0.98; for LTC, 0.22 to 0.97. Owing to considerable heterogeneity, pooled estimate points were not calculated. Other high-sensitivity tests were scaphoid tubercle tenderness, with sensitivity and specificity ranging from 0.82 to 1.00 and 0.17 to 0.57, respectively, and painful ulnar deviation, ranging from 0.67 to 1.00 and 0.17 to 0.60, respectively. Three studies showed that combining tests increased the specificity and post-test fracture probability while maintaining high sensitivity. Quality assessment showed high or unclear risk of bias and applicability concerns in reference standard and patient selection. Twelve study designs were prospective, and 1 was retrospective.
  
  
  CONCLUSIONS
  Anatomical snuff box tenderness was the most sensitive clinical test. The low specificity of the clinical tests may result in a considerable number of overtreated patients. Combining tests improved the post-test fracture probability. This can be used to limit unnecessary immobilization, number of hospital visits, and use of imaging. The data presented herein may help to develop clinical prediction rules that could increase specificity without reducing sensitivity.
  
  
  METHODS
  Diagnostic II.
authors.affiliation: Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands. Electronic address: w.h.mallee@amc.uva.nl.
authors.forename: Wouter H
authors.initials: WH
authors.lastname: Mallee
authors.affiliation: Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands.
authors.forename: Erik P
authors.initials: EP
authors.lastname: Henny
authors.affiliation: Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands.
authors.forename: C Niek
authors.initials: CN
authors.lastname: van Dijk
authors.affiliation: Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands.
authors.forename: Sjoerd P
authors.initials: SP
authors.lastname: Kamminga
authors.affiliation: Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands.
authors.forename: Wynanda A
authors.initials: WA
authors.lastname: van Enst
authors.affiliation: Department of Orthopaedic Surgery, Dutch Cochrane Center, University of Amsterdam, Academic Medical Center Amsterdam, the Netherlands.
authors.forename: Peter
authors.initials: P
authors.lastname: Kloen
mesh_terms: D003952:Diagnostic Imaging; D050723:Fractures, Bone / Q000175:diagnosis*; D006801:Humans; D021361:Scaphoid Bone / Q000293:injuries*; D012680:Sensitivity and Specificity
keywords: Clinical evaluation; diagnostic management; physical examination; scaphoid fracture