The Journal of Bone and Joint Surgery (American). 2006;88:2695-2703.
doi:10.2106/JBJS.E.01211
© 2006 The Journal of Bone and Joint Surgery, Inc.
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Diagnosis of Scaphoid Fracture Displacement with Radiography and Computed Tomography

Santiago Lozano-Calderón, MD1, Philip Blazar, MD2, David Zurakowski, PhD3, Sang-Gil Lee, MD1 and David Ring, MD1

1 Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for D. Ring: dring{at}partners.org
2 Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115
3 Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115

Investigation performed at the Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts

In support of their research for or preparation of this manuscript, one or more of the authors received an unrestricted grant from the AO Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Displacement is an important risk factor for nonunion of scaphoid wrist fractures. We compared computed tomography with radiographs with regard to their ability to detect displacement.

Methods: Six blinded observers rated thirty scaphoid fractures (ten displaced and twenty nondisplaced) with use of radiographs and computed tomography. The radiographs were evaluated separately from the computed tomography scans and then, in a third evaluation, the two imaging studies were reviewed simultaneously. The evaluations were repeated four weeks later. Observers were asked to evaluate specific measures of fracture displacement and then to judge the fracture as being displaced or nondisplaced.

Results: Intraobserver reliability was better for computed tomography alone and the combination of radiographs and computed tomography than it was for radiographs alone (kappa values, 0.65, 0.63, and 0.54, respectively; all p < 0.001). The interobserver reliability was also better for computed tomography alone and the combination of radiographs and computed tomography than it was for radiographs alone (kappa values, 0.43, 0.48, and 0.27, respectively; all p < 0.001). The average sensitivity was 75% for radiographs alone, 72% for computed tomography alone, and 80% for both; the average specificity was 64%, 80%, and 73%, respectively; the average accuracy was 68%, 77%, and 75%, respectively. The positive predictive values (assuming a 5% prevalence of fracture displacement) were low (0.10, 0.13, and 0.16) and the negative predictive values were high (0.97, 0.98, and 0.99) for the radiographs, computed tomography, and combined modality.

Conclusions: Computed tomography improves the reliability of detecting scaphoid fracture displacement but has a more limited effect on accuracy, which remains <80%. The utility of computed tomography scans for diagnosing scaphoid fracture displacement is affected by the low prevalence of fracture displacement. This study suggests that computed tomography scans are useful for ruling out displacement but not for diagnosing it. We recommend that all scaphoid fractures be evaluated with computed tomography in order to rule out displacement.

Level of Evidence: Diagnostic Level III. See Instructions to Authors for a complete description of levels of evidence.


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