贝叶斯统计分析用于评估临床检查中舟状骨骨折的诊断概率：一项荟萃分析。
Bayesian Statistics to Estimate Diagnostic Probability of Scaphoid Fractures from Clinical Examinations: A Meta-Analysis.
机构信息
From Oakland University William Beaumont School of Medicine; and the Section of Plastic and Reconstructive Surgery, Department of Surgery, Michigan Medicine.
出版信息
Plast Reconstr Surg. 2021 Mar 1;147(3):424e-435e. doi: 10.1097/PRS.0000000000007627.
BACKGROUND
Management of suspected scaphoid fractures includes repeated evaluation and casting in symptomatic patients with nondiagnostic radiographs. In this systematic review and meta-analysis, the authors compare the diagnostic accuracy of clinical examinations for scaphoid fractures and create a decision guide using Bayesian statistics.
METHODS
The MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases were queried for studies that evaluated clinical index tests and their diagnostic accuracies for scaphoid fracture. Summary estimates were achieved by a bivariate random effects model and used in Bayes' theorem. The authors varied the scaphoid fracture prevalence for sensitivity analysis.
RESULTS
Fourteen articles with 22 index tests and 1940 patients were included. Anatomical snuffbox pain/tenderness (11 studies, 1363 patients), pain with axial loading (eight studies, 995 patients), and scaphoid tubercle tenderness (five studies, 953 patients) had sufficient data for pooled analysis. Anatomical snuffbox pain/tenderness was the most sensitive test (0.93; 95 percent CI, 0.87 to 0.97), and pain with axial loading was the most specific test (0.66; 95 percent CI, 0.41 to 0.85), but all three tests had lower estimated specificities compared with sensitivities. In the base case, the probability of fracture was approximately 60 percent when a patient presented with all three findings after acute wrist injury.
CONCLUSIONS
The posttest probability of scaphoid fracture was sensitive to both prevalence and diagnostic accuracy of individual clinical index tests. In a population with a fracture prevalence of 20 percent, patients presenting with concurrent anatomical snuffbox pain/tenderness, pain on axial loading, and scaphoid tubercle tenderness may benefit from early advanced imaging to rule out scaphoid fractures if initial radiographs are nondiagnostic.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.
背景
疑似舟状骨骨折的处理包括对症状性且影像学检查无特征性表现的患者进行反复评估和固定。在本系统评价和荟萃分析中，作者比较了用于诊断舟状骨骨折的临床检查的准确性，并使用贝叶斯统计学方法制定了决策指南。
方法
在 MEDLINE、Embase 和 Cumulative Index to Nursing and Allied Health Literature 数据库中检索评估临床指数检查及其对舟状骨骨折诊断准确性的研究。使用双变量随机效应模型获得汇总估计值，并在贝叶斯定理中使用。作者根据敏感性分析改变了舟状骨骨折的患病率。
结果
纳入了 14 项研究，共涉及 22 项指数检查和 1940 例患者。有足够数据进行汇总分析的指数检查包括：解剖学鼻烟窝压痛/触痛（11 项研究，1363 例患者）、轴向加压疼痛（8 项研究，995 例患者）和舟状骨结节压痛（5 项研究，953 例患者）。解剖学鼻烟窝压痛/触痛是最敏感的检查（0.93；95%CI，0.87 至 0.97），轴向加压疼痛是最特异的检查（0.66；95%CI，0.41 至 0.85），但所有 3 项检查的特异性估计值均低于敏感性。在基线情况下，如果急性腕部损伤后患者出现这 3 种表现，骨折的可能性约为 60%。
结论
舟状骨骨折的术后概率对单个临床指数检查的患病率和诊断准确性均敏感。在骨折患病率为 20%的人群中，如果初始 X 线片无特征性表现，同时出现解剖学鼻烟窝压痛/触痛、轴向加压疼痛和舟状骨结节压痛的患者可能需要早期进行高级影像学检查以排除舟状骨骨折。
临床问题/证据水平：诊断，II 级。
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