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The diagnostic accuracy of physical examination findings and emergency medicine (<jats:styled-content style=\"fixed-case\">EM<\/jats:styled-content>) imaging studies for scaphoid fracture has not been previously described in the <jats:styled-content style=\"fixed-case\">EM<\/jats:styled-content> literature. Plain x\u2010rays are insufficient to rule out scaphoid fractures in a patient with a suggestive mechanism and radial\u2010sided tenderness on physical examination. This study was a meta\u2010analysis of historical features, physical examination findings, and imaging studies for scaphoid fractures not visualized on plain x\u2010ray in adult emergency department (<jats:styled-content style=\"fixed-case\">ED<\/jats:styled-content>) patients, specifically to address which types of imaging tests should be recommended in patients with persistent concern for acute fracture after <jats:styled-content style=\"fixed-case\">ED<\/jats:styled-content> discharge.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>A medical librarian and two emergency physicians (<jats:styled-content style=\"fixed-case\">EP<\/jats:styled-content>s) conducted a medical literature search of <jats:styled-content style=\"fixed-case\">PUBMED<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">EMBASE<\/jats:styled-content>. The original studies' bibliographies were reviewed for additional references and unpublished manuscripts were located via a hand search of <jats:styled-content style=\"fixed-case\">EM<\/jats:styled-content> research abstracts from national meetings. All abstracts were independently reviewed by the two physicians, and Quality Assessment Tool for Diagnostic Accuracy Studies (<jats:styled-content style=\"fixed-case\">QUADAS<\/jats:styled-content>\u20102) was used to assess individual study quality. When two or more qualitatively similar studies were identified, meta\u2010analysis was conducted using Meta\u2010DiSc software. Primary outcomes were sensitivity, specificity, and likelihood ratios (<jats:styled-content style=\"fixed-case\">LR<\/jats:styled-content>s) for predictors of scaphoid fracture detected on follow\u2010up in patients with normal <jats:styled-content style=\"fixed-case\">ED<\/jats:styled-content> x\u2010rays.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 957 unique citations were identified, yielding 75 studies eligible for inclusion in this systematic review. Studies were significantly heterogeneous in design, study population, and criterion standard. The majority of studies were conducted in non\u2010<jats:styled-content style=\"fixed-case\">ED<\/jats:styled-content> settings (e.g., orthopedic clinics). No studies used accepted diagnostic research publishing guidelines, and the overall <jats:styled-content style=\"fixed-case\">QUADAS<\/jats:styled-content>\u20102 methodologic quality was low, indicating an increased risk of bias in the estimates of diagnostic accuracy. The prevalence of scaphoid fractures ranged from 12% to 57% with the point estimate of 25% pretest probability for adult <jats:styled-content style=\"fixed-case\">ED<\/jats:styled-content> patients with concern for scaphoid injuries, nondiagnostic index x\u2010rays, and scaphoid fractures on later imaging studies. Except for the absence of snuffbox tenderness (<jats:styled-content style=\"fixed-case\">LR<\/jats:styled-content>\u2013\u00a0= 0.15), physical examination findings lack accuracy to rule in or rule out scaphoid fractures, and no validated clinical decision rules exist. In patients with persistent concern for injury, magnetic resonance imaging (<jats:styled-content style=\"fixed-case\">MRI<\/jats:styled-content>) is superior to bone scan, computed tomography (<jats:styled-content style=\"fixed-case\">CT<\/jats:styled-content>), or ultrasound (<jats:styled-content style=\"fixed-case\">US<\/jats:styled-content>) to both rule in and rule out scaphoid fractures. Both <jats:styled-content style=\"fixed-case\">MRI<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">CT<\/jats:styled-content> share the added benefit of identifying alternative etiologies for posttraumatic wrist pain.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Except for the absence of snuffbox tenderness, which can significantly reduce the probability of scaphoid fracture, history and physical examination alone are inadequate to rule in or rule out scaphoid fracture. <jats:styled-content style=\"fixed-case\">MRI<\/jats:styled-content> is the most accurate imaging test to diagnose scaphoid fractures in <jats:styled-content style=\"fixed-case\">ED<\/jats:styled-content> patients with no evidence of fracture on initial x\u2010rays. If <jats:styled-content style=\"fixed-case\">MRI<\/jats:styled-content> is unavailable, <jats:styled-content style=\"fixed-case\">CT<\/jats:styled-content> is adequate to rule in scaphoid fractures, but inadequate for ruling out scaphoid fractures.<\/jats:p><\/jats:sec>","DOI":"10.1111\/acem.12317","type":"journal-article","created":{"date-parts":[[2014,2,10]],"date-time":"2014-02-10T15:55:24Z","timestamp":1392047724000},"page":"101-121","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":69,"title":["Adult Scaphoid Fracture"],"prefix":"10.1111","volume":"21","author":[{"given":"Christopher R.","family":"Carpenter","sequence":"first","affiliation":[{"name":"Division of Emergency Medicine Washington University in St. Louis School of Medicine St. Louis MO"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jesse M.","family":"Pines","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine George Washington University Washington DC"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeremiah D.","family":"Schuur","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine Brigham and Women's Hospital Boston MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meaghan","family":"Muir","sequence":"additional","affiliation":[{"name":"Medical Library Brigham and Women's Hospital Boston MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryan P.","family":"Calfee","sequence":"additional","affiliation":[{"name":"Orthopedic Surgery Washington University in St. Louis School of Medicine St. Louis MO"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ali S.","family":"Raja","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine University of Cincinnati Cincinnati OH"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2014,2,10]]},"reference":[{"key":"e_1_2_8_2_1","first-page":"289","article-title":"Twenty questions about scaphoid fractures","volume":"17","author":"Barton NJ","year":"1992","journal-title":"J Bone Joint Surg Br"},{"key":"e_1_2_8_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/B978-0-323-05472-0.00048-7"},{"key":"e_1_2_8_4_1","first-page":"1807","volume-title":"Tintinalli's Emergency Medicine: A Comprehensive Study Guide","author":"Escarza R","year":"2011"},{"key":"e_1_2_8_5_1","first-page":"147","volume-title":"Evidence\u2010based Emergency Care: Diagnostic Testing and Clinical Decision Rules","author":"Pines JM","year":"2013"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0266-7681(05)80197-4"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1097\/00063110-200504000-00002"},{"key":"e_1_2_8_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0363-5023(78)80062-8"},{"key":"e_1_2_8_9_1","doi-asserted-by":"publisher","DOI":"10.3109\/17453676608989415"},{"key":"e_1_2_8_10_1","first-page":"815","volume-title":"Green's Operative Hand Surgery","author":"Amadio PC","year":"1999"},{"key":"e_1_2_8_11_1","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1302\/0301-620X.63B2.7217146","article-title":"The fractured carpal scaphoid. 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