Diagnostic accuracy of history taking physical

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Krastman et al BMC Musculoskeletal Disorders 2020 21 12 Page 2 of 24. Background during the diagnostic process which hand or wrist ana. Hand and wrist injuries are among the most common trau tomical structure or tissue soft tissue or bone is affected. matic presentations to the emergency department 1 2 Moreover these reviews focused predominantly on im. and commonly affect young people of working age 3 4 aging as a diagnostic tool while in clinical practice a diag. Scaphoid fractures are the most frequently injured carpal nosis is mainly made on history taking and physical. bones accounting for 61 90 of fractures 4 6 The diag examination. nosis of a scaphoid fracture may however be difficult to es Therefore the purpose of this literature review is to. tablish on a conventional radiograph 7 8 Previous provide an up to date systematic overview of the diag. research has shown that 10 35 of scaphoid fractures are nostic accuracy of history taking physical examination. missed on primary radiographs 4 9 12 Metacarpal frac and imaging for phalangeal metacarpal and carpal frac. tures are detected in 30 40 of all hand fractures in all tures and to distinguishing between studies in hospital. emergency department admissions 4 9 10 and non institutionalized general practitioner care set. Hand and wrist injuries represent a considerable eco tings as test properties may differ between settings. nomic burden with high health care and productivity Compared to previously published reviews in this sys. costs 13 The total costs have been estimated at US tematic review we also included studies that examined. 410 million per year with US 307 million in product history taking and physical examination for phalangeal. ivity costs 14 metacarpal or carpal fractures, If not treated properly patients with hand and wrist. injuries may experience lifelong pain and lose their job Methods. which also has major effects on their quality of life 15 Data sources and searches. Accurate diagnosis and early treatment of hand and A review protocol was drafted but central registration. wrist fractures are important because missed diagnosis was not completed The Preferred Reporting Items for. and delayed initiation of therapy increase the risk of Systematic Reviews and Meta Analyses PRISMA State. complications and subsequent functional impairment ment was used to guide the conduct and reporting of. 16 22 the study 40 A Biomedical Information specialist. In recent decades research has predominantly focused Wichor M Bramer performed a search for studies in. on imaging modalities for the diagnosis of wrist frac Medline Embase Cochrane Library Web of Science. tures However the standard diagnostic work up for Google Scholar ProQuest and Cinahl from 2000 up to 6. wrist complaints that are suspected fractures should also February 2019 This starting point was used since mul. include detailed patient history taking a conscientious tiple reviews are available that already cover the period. physical examination and only if needed imaging 23 up to the year 2000 Table 1 Search terms included. It has been shown that different provocative tests are phalangeal metacarpal and carpal injuries anamnestic. somewhat useful for diagnosing wrist fractures 24 27 assessment provocative test s diagnostic test s and im. but there is no consensus on imaging protocols due to aging tests The full electronic search strategy for the. limited evidence regarding the diagnostic performance Embase database is presented in Table 2 the others are. of these advanced imaging techniques 28 Therefore available upon request. diagnosing wrist pathologies remain complex and chal. lenging and there is increasing demand for evidence for Study selection. accurate diagnostic tools 29 Studies describing diagnostic accuracy of history taking. Diagnostic studies performed in hospital care cannot physical examination or imaging in adult patients age. automatically be translated into guidelines for non 16 years with phalangeal metacarpal and or carpal frac. institutionalized general practitioner care 30 The clin tures were included No language restriction was ap. ical utility of diagnostic tests for hand and wrist fractures plied Case reports reviews and conference proceedings. is hindered by the low prevalence of true fractures ap were excluded Distal radius and ulna injuries were also. proximately 7 on average 31 excluded as they can be diagnosed accurately with plane. Currently there are several systematic reviews available X ray or computer tomography imaging. on the diagnostic accuracy of tests for the diagnosis of Two reviewers PK YA read all titles and abstracts in. hand and wrist fractures as presented in Table 1 32 39 dependently Articles that could not be excluded on the. Of these only the review by Carpenter et al used history basis of the title and or abstract were retrieved in full. as a keyword in their search terms but they could not find text and were read and checked for inclusion by the two. studies assessing the diagnostic accuracy of history for reviewers independently If there was no agreement a. scaphoid fractures 32 All the available systematic re third reviewer JR made the final decision In addition. views only examined diagnostic tests for scaphoid frac the reference lists of all included studies were reviewed. tures 32 39 while in practice it is often not quite clear to check for additional relevant studies. Krastman et al BMC Musculoskeletal Disorders 2020 21 12 Page 3 of 24. Table 1 Characteristics of the Currently Available Systematic Reviews on the Diagnostic Accuracy of Tests. Author s Population in eligible Fracture Number Diagnostic Pooled Se Pooled Sp Positive LR Conclusion. studies as described of studies test 95 CI 95 CI,by the review authors included. HISTORY TAKING, Carpenter Emergency Scaphoid 0 History examination alone is. 2014 32 Department inadequate to rule in or rule,out scaphoid fracture. PHYSICAL EXAMINATION, Carpenter Emergency Scaphoid 6 ASB tenderness 0 96 0 92 0 98 0 39 0 36 0 43 Except for the absence of.
2014 32 Department snuffbox tenderness which, 6 LTC 0 82 0 77 0 87 0 58 0 54 0 62 can significantly reduce the. 7 Ultrasound 0 67 0 59 0 75 0 57 0 51 0 62 probability of scaphoid. fibration pain fracture physical examination,alone is inadequate to rule in. 3 Clamp sign 0 73 0 67 0 78 0 92 0 89 0 95 or rule out scaphoid fracture. 3 Painfull ulnar 0 77 0 68 0 83 0 42 0 34 0 49,3 STT 0 92 0 86 0 96 0 47 0 43 0 52. 2 Resisted 0 94 0 85 0 98 0 74 0 63 0 84,supination. Burrows Not specified Scaphoid 5 ASB tenderness 1 52 1 12 2 06 Three clinical tests with. 2014 33 statistically significant, 7 Scaphoid 2 37 1 27 4 41 diagnostic validity were.
compression identified In isolation the,test clinical significance of each is. 3 STT 1 67 1 33 2 09 questionable, Mallee Patients presenting Scaphoid 8 ASB tenderness 0 87 1 00 0 03 0 98 Anatomical snuff box. 2015 34 to the emergency a b tenderness was the most. department or 8 LTC 0 48 1 00 0 22 0 97 sensitive clinical test The low. outpatient clinic 4 STT 0 82 1 00 a,0 17 0 57 b specificity of the clinical tests. may result in a considerable, 4 Painfull ulnar 0 67 1 00 0 17 0 60 number of over treated. deviation patients Combining tests,a b improved the post test.
4 ASB swelling 0 67 0 77 0 37 0 72,fracture probability. Carpenter Emergency Scaphoid 5 X ray fat pad 0 82 0 76 0 86 0 72 0 68 0 75 MRI is the most accurate. 2014 32 Department imaging test to diagnose, 18 BS 0 91 0 87 0 94 0 86 0 83 0 88 scaphoid fractures in ED. 6 US 0 80 0 67 0 90 0 87 0 81 0 91 patients with no evidence of. fracture on initial x rays If, 8 CT 0 83 0 83 0 89 0 97 0 94 0 98 MRI is unavailable CT is ad. equate to rule in scaphoid,13 MRI 0 96 0 92 0 99 0 98 0 96 0 99. fractures but inadequate for,ruling out scaphoid fractures.
Yin 2012 35 Not specified Scaphoid 28 Follow up 0 91 0 81 0 98 1 00 0 99 1 00 If we acknowledge the lack. radiographs of a reference standard for,diagnosing suspected. 18 BS 0 98 0 96 0 99 0 94 0 91 0 95 scaphoid fractures MRI is the. 15 MRI 0 98 0 95 0 99 1 00 0 99 1 00 most accurate test follow up. radiographs and CT may be, 9 CT 0 85 0 74 0 94 1 00 0 98 1 00 less sensitive and bone. scintigraphy less specific, Yin 2010 36 Not specified Scaphoid 15 BS 0 97 0 93 0 99 0 89 0 83 0 94 Bone scintigraphy and MRI. have equally high sensitivity, 10 MRI 0 96 0 91 0 99 0 99 0 96 1 00 and high diagnostic value for. 6 CT 0 93 0 83 0 98 0 99 0 96 1 00 excluding scaphoid fracture. however MRI is more specific,and better for confirming.
scaphoid fracture, Mallee People of all ages Scaphoid 6 BS 0 99 0 69 1 00 0 86 0 73 0 94 Bone scintigraphy is. 2014 34 who presented at statistically the best, hospital or clinic 4 CT 0 72 0 36 0 92 0 99 0 71 1 00 diagnostic modality to. 5 MRI 0 88 0 64 0 97 1 00 0 38 1 00 establish a definitive. diagnosis in clinically,suspected fractures when,radiographs appear normal. The number of overtreated,patients is substantially lower. Krastman et al BMC Musculoskeletal Disorders 2020 21 12 Page 4 of 24. Table 1 Characteristics of the Currently Available Systematic Reviews on the Diagnostic Accuracy of Tests Continued. Author s Population in eligible Fracture Number Diagnostic Pooled Se Pooled Sp Positive LR Conclusion. studies as described of studies test 95 CI 95 CI,by the review authors included.
with CT and MRI, Kwee Not specified Scaphoid 7 US 0 86 0 74 0 93 0 84 0 72 0 91 Ultrasound can diagnose. 2018 37 radiographically occult,scaphoid fracture with a fairly. high degree of accuracy, Ali 2018 38 Not specified Scaphoid 6 US 0 94 0 78 1 00 0 89 0 78 1 00 US reveals high sensitivity. and specificity in scaphoid,fracture diagnosis, ASB Anatomic snuff box LTC Longitudinal thumb compression test STT Scaphoid tubercle tenderness BS Bone Scintigraphy US Ultrasound CT Computed. TomographyMRI Magnetic Resonance Imaging, Sensitivity range described because of the high heterogeneity Mallee et al 34 refrained from calculating pooled estimate points.
Specificity Range described because of the high heterogeneity Mallee et al 34 refrained from calculating pooled estimate points. Data extraction and methodological quality assessment Reference standard. Two reviewers PK JR independently extracted the There is no consensus about the reference test for the. data Data were extracted describing the study design diagnosis of a true fracture of the phalangeal metacarpal. characteristics of the study population test characteris or carpal bones 35 Therefore in this systematic review. tics study population setting hospital care or non clinical outcome physical examination or additional. institutionalized general practitioner care and diagnostic treatment and or various combined imaging modal. parameters Methodological quality was assessed by two ities during follow up were used as the reference stand. independent reviewers PK JR using the Quality As ard for confirming diagnosis of phalangeal metacarpal. sessment of Diagnostic Accuracy Studies QUADAS 2 or carpal fractures. checklist 41 Disagreements were resolved by,discussion Results. The flow diagram is presented in Fig 1 A total of 35. diagnostic studies were identified assessed and inter. Heterogeneity preted The characteristics of these studies are presented. Key factors in a meta analysis are the number and the in Table 3 20 studies were performed in an emergency. methodological quality of the included studies and the department four studies in a traumatology setting and. degree of heterogeneity in their estimates of diagnostic three other studies in a radiology department The pa. accuracy 42 Heterogeneity in diagnostic test accuracy tients in the studies by Mallee et al 56 58 were de. reviews is expected and the possibilities of performing rived from one prospective study therefore the setting. meta regression analyses will depend on the number of was the same for each study patients were initially seen. studies available for a specific index test that provide by the emergency physicians and in follow up by the. sufficient information 39 The data from the included orthopaedic department and or trauma surgery depart. studies were combined when studies showed no limita ment depending on who was on call In five studies the. tions according to QUADAS 2 and had no other forms setting was not specified To our knowledge all first au. of bias e g incorporation bias thors of those five studies were working in a hospital. care setting so we assume all to have been done in hos. Data synthesis and analysis pital care History taking physical examination and im. The following values were extracted if documented sen aging as index tests were investigated in 0 20 7 35. sitivity Se specificity Sp accuracy positive predictive 48 53 62 64 67 73 77 and 86 30 35 43 47 49. value PPV negative predictive value NPV and likeli 51 53 61 63 65 66 68 77 of the studies respectively. hood ratio LR If these diagnostic outcomes were not. reported they were calculated using published data If Quality assessment. an included study presented results from multiple inde There was considerable underreporting of important. pendent observers the measures of Se Sp accuracy quality domains in 23 of the 35 studies see Table 4 In. PPV and NPV were averaged over the observers 13 of the 35 studies 43 44 48 50 54 55 59 64 67 72. 74 76 77 patient selection was not well documented. Furthermore the risk of bias was predominantly due to. Background The standard diagnostic work up for hand and wrist fractures consists of history taking physical examination and imaging if needed but the supporting evidence for this work up is limited The purpose of this study was to systematically examine the diagnostic accuracy of tests for hand and wrist fractures Methods A systematic search for relevant studies was performed

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