Scaphoid fractures: a higher order analysis of clinical tests and application of clinical reasoning strategies.

INTRODUCTION The purpose of this study was to identify clinical tests for scaphoid fractures and, using a higher order analysis, to determine their diagnostic accuracy. METHODS A literature review of the databases CINAHL, Embase, Medline and PUBMED from 1980 to September 30, 2011 was conducted to obtain applicable literature on clinical tests used in identifying scaphoid fractures. Methodological quality was determined using the criteria for validity suggested by Sackett et al (2000). Using a random effects model, pooled positive likelihood ratios (PPLR) were established for any test evaluated in at least 3 published studies. Moderator analyses provided insight into heterogeneity of results. RESULTS Higher order analysis indicated that the scaphoid compression test, anatomical snuffbox tenderness and scaphoid tubercle tenderness demonstrated statistically significant ability to identify scaphoid fractures with PPLR of 2.37 (1.27-4.41), 1.52 (1.12-2.06) and 1.67 (1.33-2.09) respectively. Descriptive factors (gender and mechanism of injury) were also identified but did not demonstrate significant diagnostic ability. Pooled data revealed the existence of heterogeneity for the three clinical tests and descriptive factors, which could not be easily explained. CONCLUSION Three clinical tests with statistically significant diagnostic validity were identified. In isolation, the clinical significance of each is questionable. Further studies with description of sample characteristics, blinded assessments, and agreement on a reference standard are recommended.