Received Date: April 23, 2016; Accepted Date: June 09, 2016; Published Date: June 16, 2016
Citation: Madadi F, Madadi F, Moghaddam AS (2016) Diagnostic Value of Imaging Modalities for Suspected Calcaneal Fracture: A Systematic Review of Literatures. Clin Res Foot Ankle 4:186. doi: 10.4172/2329-910X.1000186
Copyright: © 2016 Madadi F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Background: Calcaneal fracture account as the most common tarsal bones injury. Diagnosis of fracture is based on X-rays radiological studies, but CT-scan is the most reliable tool for diagnosis of calcaneus fracture. In this study, we conducted a systematic review, which will help readers to get a better view of usefulness of different imaging modality in diagnosis of calcaneal fracture.
Methods: We conducted a systematic review based on PRISMA protocol. To find all citations, PubMed /Medline, ISI web of knowledge, EMBASE and Cochrane library databases were searched from their beginning to June 2015. Two authors, applying the inclusion and exclusion criteria, screened all citations and abstracts and extracted all needed information from included literatures, independently. In order to assess the quality of included studies, QUADAS was used.
Results: Ten literatures included in this systematic review. Sensitivity of different conventional radiographs ranged from 0% for Foot posteroanterior to 100% for Foot reversed oblique and Combined Lateral and axial calcaneal X-ray. Specificity of conventional radiographs ranged from 72% for lateral calcaneal X-ray to 100% for Lateral foot or ankle radiograph. For the CT-scan, three-dimensional (3D) shaded radiographs had highest sensitivity (90.7%) and specificity (93.9%). Four studies tried to show value of angle’s measures in diagnosis of calcaneal fracture that had different results. Conclusions: We concluded that there are few literatures evaluating different imaging modality in diagnosis of calcaneal fracture and results are not enough to prove advantage of one modality to others. So, one study with a large population sample is needed to compare diagnostic value of different modalities.
Diagnostic; Imaging; Calcaneal fracture; Calcaneus; Systematic review
Calcaneal fractures account as the most common tarsal bones injury . Therefore, definite diagnosis of calcaneal fracture is an important element for proper management. The main signs and symptoms of fractures are swelling and deformity. Diagnosis of fracture is based on X-rays radiological studies . Two main landmark of lateral view X-ray are Böhler’s and Gissane’s angles and the axial view has advantage for evaluation of Varus deformity of the calcaneus andwidening of the heel .
Early diagnosis of fracture facilitates treatment of fracture and may reduce complications. In addition, knowing the best way of diagnosis may decrease economic burden and accelerate proper management of patients. Nowadays, CT-scan is the most reliable tool for diagnosis of calcaneus fracture  and CT-scan is more accurate for assessment of fracture. Detecting stress fractures of the calcaneus can be made by Technetium scans and MRI, but it is not appropriate to apply them in the acute setting .
Because of limited studies evaluating diagnostic value of different modalities in calcaneal fracture, we conducted a systematic review, which will help readers to get a better view of usefulness of different imaging modality.
We conducted a systematic review based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol .To retrieve all relevant literatures, a sensitive search queryconsisted of terms related to calcaneus ("calcaneus"[Mesh]) combined with specific terms for fracture ("Fractures, Bone"[Mesh]), Evaluation Studies as Topic"[Mesh]) and diagnosis ("Diagnosis"[Mesh]) was used. PubMed /Medline, ISI web of knowledge, EMBASE and Cochrane library databases were searched from their beginning to June 2015 to find all citations (Updated in May 2016). Detailed search strategy results of each database are reported in supplementary appendix. There was no limitation in search of databases. In addition, a search of reference list of included studies, systematic reviews and meta-analysis was conducted in order to find missed citations.
The literatures met inclusion criteria if:  evaluated calcaneal fracture;  had reported or calculable diagnostic accuracy statistics (sensitivity, specificity, positive likelihood ratio, negative likelihood ratio);  offered a diagnostic methodology to differentiate between fractured bone and non-fractured bone;  had available full text;  written in English language. The citations with following conditions were excluded:  case-reports;  review studies; non-research article (all type of letters, comments, and editorial);  cadaveric studies;  animal studies.
Selection procedure and data extraction
Two authors, applying the inclusion and exclusion criteria, screened all citations and abstracts and extracted all needed information from included literatures, independently. When conflicting results was seen between reviewers, a third author (senior researcher) discussed about disagreement. EndNote X7 software was used to manage review and organize screening.
The following information and data extracted: name of first author, date of publication, study objective (what authors aimed to conclude), study population, gender and mean age of population, criterion standard, imaging modality and diagnostic accuracy statistics.Finally, senior author rechecked all information of final stage table. For clarifications and more information (or unavailable full texts), we contacted with first and corresponding authors to provide additional data.
Literature quality assessment
In order to assess quality of included studies, QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool  was employed. QUADAS tool have 14 items with answers “yes”, “no” and “unclear” and we scored one to answer “yes” and zero to answers “no” and “unclear”. We considered studies with score < 5 as low quality score 5-9 as moderate quality and score ≥ 10 as high quality. The quality of studies assessed by two authors, applied the methodology of QUADAS tool.
In the first electronic search of databases, 2,537 citations were identified, in which 809 citations were removed due to duplication. Title and abstract screening gave us 39 full-texts. Finally, after detailed full-text assessment, and additional search of reference lists, 10 literature included in this systematic review [7-16] (Figure 1). Among included studies, six were conducted in Europe, three in United States of America (USA), one in Asia (china) and one in Australia. Six studies evaluated value (sensitivity and specificity) of different radiographical approach and four studies had a measuremental approach (assessment of angles, heights and lengths) for calcaneal fracture. Of these included studies, six had moderate quality and quality of four studies was low. We found no high-quality study evaluating diagnostic tools in calcaneal fracture. Detailed characteristics of studies are presented in Table 1.
|First author||Date||Country||Objective||Participants||Gender||Age||Criterion standard||Imaging modality||Diagnostic accuracy statistics||QUADAS Score|
|Zhang, T.||2015||China||test the value of axial view in diagnosing calcaneal fracture||140 Patients older than 18 yr with suspected calcaneal fractures||MF||39.2 yr (19-61)||CT scan||Combined calcaneal lateral and axial X-rays||Sn: 98.97% Sp:95.35%||9|
|Calcaneal single lateral X-ray||Sn: 94.85% Sp: 79.07%|
|Arslan, G.||2014||Turkey||determine whether calcaneal fracture severity determined by angle and facet height measurements on lateral X-ray radiographs correlate with the Sanders classiﬁcation||69 patients diagnosed with calcaneal fractures and 50 individuals without calcaneal pathology as control group||MF||39 yr (18-79) cases/42 yr (19-88) controls||NS||digital lateral view X-ray images and multi planar reformatted contrast-enhanced CT images with slices measuring 1 mm||Cnl||EA-FX||IA-FX||1|
|BA||42.08 ± 8.8||38.9 ± 9.48 P=0.186||28.62 ± 15.73 P<0.001|
|AoG||106.04 ± 8.22||112.8 ± 8.16 P=0.003||118.94 ± 13.08 P<0.001|
|FH (mm)||45.96 ± 3.52||46.1 ± 3.51 P=0.881||43.42 ± 5.71 P=0.006|
|IL||21.14 ± 4.85||18.6 ± 3.6 P=0.038||18.33 ± 5.06 P=0.003|
|Isaacs, J. D.||2013||Australia||conﬁrm the normal range for Bohler’s angle and determine the angle with the highest accuracy in the diagnosis of calcaneal fractures||212 consecutive patients diagnosed with calcaneal fractures and 212 patients with normal lateral foot radiographs||MF||35.8 yr (cases)/50.9 (controls)||CT scan||Lateral radiographs||Sn||Sp||PPV||NPV||LR+||LR-||8|
|Schepers, T.||2007||Netherlands||Correlate the functional outcome after treatment for displaced intra- articular calcaneal fracture with plain radiography||33 patients with a unilateral calcaneal fracture||MF||46 yr ( 18–65)||NS||Weight-bearing lateral and axial view||Cnl||Case||3|
|Böhler angle||32 (25–40)||16 (−10–40) P<0.001|
|Gissane angle||108 (90–125)||113 (80–140) P=0.023|
|Facet inclination angle||66 (51–80)||54 (15–75) P<0.001|
|Tibiotalar angle||105 (94–128)||103 (92–110) P=0.101|
|Talar declination angle||20 (15–28)||16 (10–26) P<0.001|
|Calcaneal inclination angle||23 (12–33)||21 (13–29) P=0.028|
|Talocalcaneal angle||43 (32–58)||37 (23–57) P<0.001|
|Tibiocalcaneal angle||62 (45–81)||65 (35–80) P=0.011|
|Calcaneal width (mm)||40 (35–46)||46 (37–56) P<0.001|
|Calcaneal facet height (mm)||50 (43–56)||47 (38–58) P=0.001|
|Absolute foot height (mm)||81 (67–92)||77 (65–90) P<0.001|
|Calcaneal length (mm)||82 (71–93)||82 (71–92) P=0.701|
|Knight, J. R.||2006||USA||determine the use of Boehler’s angle (BA) and the critical angle of Gissane (CAG) in diagnosing calcaneus fractures in the ED||65 patients with CT–verified calcaneus fractures and 68 ED patients with lateral foot or ankle x-rays without calcaneus fractures||NS||NS||CT scan||Lateral foot or ankle radiograph||Emergency physicians’ accuracy: 97.9% (97%-99%) Radiologist Sn: 98.5% Radiologist Sp: 100%||8|
|Geusens, E.||2000||Belgium||demonstrate the statistical significance of a reversed oblique radiograph of the foot in patients with ankle or foot trauma||100 consecutive patients who presented with a blunt trauma of ankle and/ or foot (8 calcaneal fractures of 29 total fractures)||NS||NS||NS||Foot posteroanterior,||*Sn: 0%||4|
|Foot oblique||*Sn: 12.5%|
|Foot reversed oblique||*Sn: 100%|
|Utukuri, M. M.||2000||UK||sensitivity and specificity of the lateral view alone and lateral and axial views combined||Fifty sets of calcaneal radiographs||NS||NS||Clinical course of the patients, further radiographs and CT scans||Lateral calcaneal X-ray||Sn||Sp||PPV||NPV||4|
|Combined Lateral and axial calcaneal X-ray||Sn||Sp||PPV||NPV|
|Tanyu, M. O.||1994||Germany||Value of 3D-CT imaging compared to conventional X-rays and 2D CT scans in calcaneal fracture assessment||23 patients with different types of acute calcaneus fractures||MF||20-68 yr||NS||Nondiagnostic||Moderate diagnostic value||Good diagnostic value||Excellent diagnostic value||6|
|Richardson, M. L.||1992||USA||Investigate methods of estimating the calcaneus varus angle in normal and fractured hind foot and to stablish normative data for each method||48 consecutive patients with known or suspected calcaneal fracture||MF||37 yr (19-71)||CT scan||CT scan||Axial calcaneocuboid angle||Axial talocalcaneal angle||Coronal talocalcaneal angle||9|
|Normal foots||25.3 ± 7.3||20.9 ± 9.2||12.5 ± 3.8|
|Fractured foots||28.9 ± 8.5 P=0.05||29.2 ± 11.3 P=0.001||21.8 ± 7.6 P<0.001|
|Vannier, M. W.||1991||USA||compare the diagnostic sensitivity and specificity of 3D CT, CT slices, and plain radiography in the detection and characterization of calcaneal and pelvic fractures||Nineteen calcanei in 11 individuals with suspected or overt calcaneal fractures||MF||NS||NS||Accuracy||Sn||Sp||5|
Table 1: Characteristics of studies included in the systematic review evaluating the Diagnostic Value of imaging modalities for suspected calcaneal fracture.
Conventional radiography (X-ray)
Six studies evaluated diagnostic accuracy of different views of conventional radiographs[7,11-14,16] . Of these, four had moderate quality. Sensitivity of different conventional radiographs ranged from 0% for foot posteroanterior to 100% for Foot reversed oblique and combined lateral and axial calcaneal X-ray[12,13]. Specificity of conventional radiographs ranged from 72% for lateral calcaneal X-ray  to 100% for lateral foot or ankle radiograph[11,16]. Just one study reported positive and negative predictive value.
Computed tomography scan (CT-scan)
Only two studies assessed role of CT-scan in diagnosis of calcaneal fracture[14,16]. Both studies had moderate quality, but just one of them reported sensitivity and specificity of different types of CT-scan. Three-dimensional (3D) shaded radiographs had highest sensitivity (90.7%) and specificity (93.9%).
Four studies tried to show value of angle’s measures in diagnosis of calcaneal fracture in which two of them had moderate quality. Three of these worked on Böhler angle[8-10]. Two studies just showed significant difference of Böhler angle between fractured and non-fractured calcaneus[8,10]. One presented sensitivity and specificity of different amount of Böhler angle. This study concluded Böhler angle of 20° or less is highly accurate in diagnosis of calcaneal fracture. Among other measurements, just tibiotalar angle and calcaneal length showed no significant difference between fractured and non-fractured calcaneus.
We identified no literature evaluating diagnostic accuracy of ultrasonography and magnetic resonance imaging (MRI).
As a part of a systematic review, we aimed to address diagnostic accuracy and diagnostic value of different radiographs and tools through identification of relevant studies. Totally, 10 studies identified through search of four major databases and there were limit number of literatures evaluating diagnostic accuracy of different radiographs. In addition, we found no study with high-quality design and findings showed lack of high-quality study in assessment of diagnostic accuracy different tools in calcaneal fracture. These evidences are convincing enough that conclusions of this study are not completely reliable for clinical implication.
Conventional radiography showed a wide range of Sensitivity and specificity in diagnosis of calcaneal fracture. Although, most of studies presented a high sensitivity and specificity, but two studies showed lack of diagnostic value for some views of conventional radiography[13,14]. Also, results demonstrated that combined lateral and axial calcaneal X-ray have higher diagnostic accuracy compared to lateral calcaneal X-ray alone. Böhler angle and Gissane’s angle are two important markers of lateral X-ray. Axial view is useful for assessment of calcaneal varusdeformity,heel widening, step-off in the posterior facet and its relation with the sustentaculumtali.
CT-scan generally is considered as high sensitive and specific tools for diagnosis of fractures. In this systematic review CT-scan had used for confirmation of calcaneus fracture in most studies and only two studies evaluated importance of CT-scan in diagnosis of calcaneal fracture[14,16]. Although, there is no strong evidences to prove importance of CT-scan, but these two studies had controversial results. Vannier et al.  revealed higher accuracy, sensitivity and specificity of plain radiography compared to different types of CT-scan. On contrast, Tanyu et al.  showed superior diagnostic value of CT-scan for calcaneal fracture.
Although, some studies assessed value of angles in diagnosis of calcaneal, but only one study presented angle cut of points for diagnosis of calcaneal fracture. Isaacs et al.  evaluated diagnostic value of different Böhler angles and revealed highest diagnostic value for Böhler angle of 20° or less.
The limitation of this review was that few of studies have been evaluated diagnostic value of different tools. As well as, variation in diagnostic tools and low quality studies affected the worth of results. Definitely, experiences of physician for assessment of radiograph as a confounder variable have an important role in results of studies and there was lack of information.
However, CT is considered the gold standard, but in this systematic review, we showed lack of strong evidences to confirm advantages of CT-scan. Excellence of CT-scan may be upon unreliable evidences and use of plain radiograph can decrease economic burden. We concluded there are few literatures evaluating different tools in diagnosis of calcaneal fracture and results are not enough to prove advantage of one modality to others. So, one study with a large population sample is needed to compare diagnostic value of different modalities.
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