Wright AA, Hegedus EJ, Lenchik L, Kuhn KJ, Santiago L, Smoliga JM. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice.
Am J Sports Med 2016;
44:255-63. [PMID:
25805712 DOI:
10.1177/0363546515574066]
[Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND
The literature is filled with conflicting findings regarding diagnostic accuracy and protocols for imaging suspected lower extremity stress fractures. The absence of systematic reviews on this topic has limited the development of evidence-based recommendations for appropriate imaging protocols in cases of suspected lower extremity stress fractures.
PURPOSE
To determine the diagnostic accuracy statistics of imaging modalities used to diagnose lower extremity stress fractures and to synthesize evidence-based recommendations for clinical practice.
STUDY DESIGN
Systematic review.
METHODS
A generic search strategy for published studies was performed using multiple databases. A study was eligible for inclusion if it met all of the following criteria: (1) at least 1 diagnostic imaging modality was studied, (2) at least 1 radiological reference standard was used, (3) the study reported or allowed computation of diagnostic accuracy statistics (sensitivity, specificity, positive likelihood ratio, negative likelihood ratio), (4) a full-text version was available, (5) the article was written in English, and (6) the study included lower extremity stress fractures. Studies that examined asymptomatic individuals or patients with fractures due to disease or pharmacologic intervention were excluded.
RESULTS
Reported sensitivity and specificity (95% CI) were as follows: For conventional radiography, sensitivity ranged from 12% (0%-29%) to 56% (39%-72%) and specificity ranged from 88% (55%-100%) to 96% (87%-100%). For nuclear scintigraphy (NS), sensitivity ranged from 50% (23%-77%) to 97% (90%-100%) and specificity from 33% (12%-53%) to 98% (93%-100%). For magnetic resonance imaging (MRI), sensitivity ranged from 68% (45%-90%) to 99% (95%-100%) and specificity from 4% (0%-11%) to 97% (88%-100%). For computed tomography, sensitivity ranged from 32% (8%-57%) to 38% (16%-59%) and specificity from 88% (55%-100%) to 98% (91%-100%). For ultrasound, sensitivity ranged from 43% (26%-61%) to 99% (95%-100%) and specificity from 13% (0%-45%) to 79% (61%-96%).
CONCLUSION
MRI was identified as the most sensitive and specific imaging test for diagnosing stress fractures of the lower extremity. When MRI is available, NS is not recommended because of its low specificity, high dosage of ionizing radiation, and other limitations. Conventional radiographs are likely to result in false negatives upon initial presentation, particularly in the early stages of stress fracture, and in some cases may not reveal an existing stress fracture at any time. A diagnostic imaging algorithm was developed with specific recommendations for cost-efficient imaging of low-risk and high-risk suspected stress fractures.
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