ORIGINAL ARTICLE Reliability of Bone Scintigraphy for Suspected Scaphoid Fractures Frank J. P. Beeres, MD,* Mike Hogervorst, MD,† Steven J. Rhemrev, MD,* Saskia Le Cessie, PhD,‡ Jan Willem Arndt, MD,§ Marcel P. M. Stokkel, MD, PhD,¶ Kees A. Bartlema, MD, and Jaap F. Hamming, Prof, MD, PhD Purpose: To examine the observer variation for bone scintigraphy in the detection of occult scaphoid fractures in daily practice, using only the early bone scanning images. Methods: One hundred bone scans of patients with a suspected scaphoid fracture but negative initial radiographs were prospectively included to calculate the inter- and intraobserver variation. Three nuclear medicine physicians independently evaluated all bone scans at 2 different points in time with a 3-month interval. The observers filled out a blinded scoring sheet for each patient. They scored if a scaphoid fracture was present or not. In addition, they scored the presence or absence of another fracture. The inter- and intraobserver variation was analyzed using the  statistic. Results: The interobserver variation showed substantial agreement for a scaphoid fracture and almost perfect agreement for another fracture. The intraobserver variation showed almost perfect agree- ment for both a scaphoid fracture and another fracture. Conclusions: In the present study, early static images of bone scintigraphy for suspected scaphoid fractures showed very little inter- and intraobserver variation. In addition, expertise does not seem to have a negative influence on the results. This enhances the possibility of using bone scintigraphy in daily practice. Key Words: scaphoid fracture, bone scintigraphy, consistency, observer variation (Clin Nucl Med 2007;32: 835– 838) B one scintigraphy has been used in diagnosing fractures at all sites since the 1960s. 1 As the scaphoid bone requires a fast and reliable diagnostic approach, many diagnostic modalities other than bone scintigraphy have been advocated. Initial radiographs will detect approximately 80% of the patients with a scaphoid fracture when present. 2,3 Repeated radiographs do not lead to an improvement of the diagnostic accuracy, because the added sensitivity is low. Recently, data in the literature have demonstrated a high sensitivity and specificity for both magnetic resonance imaging and com- puted tomography. 3–7 However, until now, no proper pro- spective comparative study has been undertaken to clearly evaluate their power, reliability, and usefulness in daily practice. Currently, bone scintigraphy is being advocated as the gold standard to detect occult scaphoid fractures as it has a sensitivity of almost 100%. 8 –10 However, information con- cerning consistency of the diagnosis on bone scintigraphy is limited. One study reported moderate inter- and intraobserver agreement of early bone scanning. 11 An almost perfect agree- ment was found when both the dynamic and static phases were evaluated. If early static bone scintigraphy would be as reliable and consistent, bone scintigraphy would be more cost effec- tive in daily practice and could therefore strengthen the position of bone scintigraphy in detecting occult scaphoid fractures. The objective of the present study was to evaluate prospectively the observer variation of bone scintigraphy in the detection of occult scaphoid fractures, using only the early static bone scanning images. PATIENTS AND METHODS Patients One hundred consecutive patients, who visited the Emergency Department between 2003 and 2006 with clinical signs, but without radiologic evidence of a scaphoid fracture, were enrolled in a prospective study. All patients had a tender anatomic snuffbox, pain when applying axial pressure (first or second digit), and a recent history of acute trauma. All patients were older than 18 years. The 100 patients included 56 men and 44 women of mean age 40 (range, 18–84). In 3 patients, bilateral scaphoid fractures were suspected. Scaphoid Radiographs Initial scaphoid radiographs were performed in 3 planes: (1) an anterior–posterior view with the hand in the neutral position, (2) an oblique view with the hand in 10 Received for publication January 2, 2007; revision accepted March 12, 2007. From the *Department of Surgery, Medical Centre Haaglanden, The Hague, The Netherlands; †Department of Surgery, Gelre Ziekenhuizen, Apel- doorn, The Netherlands; ‡Department of Medical Statistics and Bioin- formatics, Leiden University Medical Centre, Leiden, The Netherlands; §Department of Nuclear Medicine, Medical Centre Haaglanden, The Hague, The Netherlands; ¶Department of Nuclear Medicine, Leiden University Medical Centre, Leiden, The Netherlands; and Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands. Reprints: F.J.P. Beeres, MD, Secretariaat Heelkunde, Medical Centre Haag- landen, Postbus 432, 2501 CK, The Hague, The Netherlands. E-mail: f.j.p.beeres@lumc.nl. Copyright © 2007 by Lippincott Williams & Wilkins ISSN: 0363-9762/07/3211-0835 Clinical Nuclear Medicine • Volume 32, Number 11, November 2007 835