Diagnostic Accuracy of Computed Tomography for Radiographically Occult Scaphoid Fractures and Concordance With Magnetic Resonance Imaging: A Systematic Review.

Abstract

Scaphoid fractures are the most common carpal bone fracture. Non-union and avascular necrosis are complications of a missed fracture. Therefore, if plain radiographs are normal and symptoms persist, further imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) are often performed. Previous systematic reviews have largely compared their diagnostic accuracy indirectly using separate patient cohorts. Our objective is to determine the diagnostic accuracy of CT for occult scaphoid fractures in patients who underwent both CT and MRI following a negative or equivocal initial radiograph, and to assess concordance between CT and MRI findings. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. OVID MEDLINE, OVID Embase, and the Cochrane Library were searched for studies published from inception up to August 31, 2026. Eligible studies enrolled adults with clinically suspected scaphoid fracture and a negative or equivocal initial radiograph who subsequently underwent both CT and MRI. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). Studies affected by partial verification or incorporation bias were excluded from quantitative synthesis. CT sensitivity and specificity were pooled using a bivariate random-effects model. Concordance between CT and MRI was reported using percentage agreement and Cohen's kappa. Eight studies met the inclusion criteria. Six studies contributed to the primary pooled analysis of CT diagnostic accuracy, with one study reporting two CT readers. Using the first reader data from that study, alongside the five other studies, pooled CT sensitivity was 79% (95% CI 61.5-89.8%) and specificity was 94.4% (95% CI 82.1-98.4%). A sensitivity analysis using the second reader produced a sensitivity of 69.2% (95% CI 48.0-84.6%), with an unchanged specificity of 94.4% (95% CI 85.5-98.0%). Three studies provided CT-MRI concordance data; two demonstrated almost perfect agreement, with Cohen's kappa values of 0.91. The dual-energy CT study demonstrated lower concordance. Three studies used a reference standard independent of both CT and MRI and demonstrated mixed comparative findings. Overall, one study was judged to have low risk of bias, and seven were high risk of bias. In the included studies, CT demonstrated high specificity but more limited sensitivity for occult scaphoid fracture in paired CT-MRI cohorts. These findings align with existing literature reviewing unpaired data sets. Therefore, the findings suggest that CT remains a relevant alternative to MRI, especially in centres where MRI is unavailable or contraindicated, or for surgical planning.