Editor's Choice| Volume 47, ISSUE 8, P709-718, August 2022

A Machine Learning Algorithm to Estimate the Probability of a True Scaphoid Fracture After Wrist Trauma


      To identify predictors of a true scaphoid fracture among patients with radial wrist pain following acute trauma, train 5 machine learning (ML) algorithms in predicting scaphoid fracture probability, and design a decision rule to initiate advanced imaging in high-risk patients.


      Two prospective cohorts including 422 patients with radial wrist pain following wrist trauma were combined. There were 117 scaphoid fractures (28%) confirmed on computed tomography, magnetic resonance imaging, or radiographs. Eighteen fractures (15%) were occult. Predictors of a scaphoid fracture were identified among demographics, mechanism of injury and examination maneuvers. Five ML-algorithms were trained in calculating scaphoid fracture probability. ML-algorithms were assessed on ability to discriminate between patients with and without a fracture (area under the receiver operating characteristic curve), agreement between observed and predicted probabilities (calibration), and overall performance (Brier score). The best performing ML-algorithm was incorporated into a probability calculator. A decision rule was proposed to initiate advanced imaging among patients with negative radiographs.


      Pain over the scaphoid on ulnar deviation, sex, age, and mechanism of injury were most strongly associated with a true scaphoid fracture. The best performing ML-algorithm yielded an area under the receiver operating characteristic curve, calibration slope, intercept, and Brier score of 0.77, 0.84, −0.01 and 0.159, respectively. The ML-derived decision rule proposes to initiate advanced imaging in patients with radial-sided wrist pain, negative radiographs, and a fracture probability of ≥10%. When applied to our cohort, this would yield 100% sensitivity, 38% specificity, and would have reduced the number of patients undergoing advanced imaging by 36% without missing a fracture.


      The ML-algorithm accurately calculated scaphoid fracture probability based on scaphoid pain on ulnar deviation, sex, age, and mechanism of injury. The ML-decision rule may reduce the number of patients undergoing advanced imaging by a third with a small risk of missing a fracture. External validation is required before implementation.

      Type of study/level of evidence

      Diagnostic II.

      Key words

      JHS Podcast

      August 2, 2022

      JHS Podcast Episode 77

      Dr. Graham interviews Dr. Anne Eva Bulstra about her paper “A Machine Learning Algorithm to Estimate the Probability of a True Scaphoid Fracture After Wrist Trauma”, which is the lead article in the August 2022 issue of the Journal of Hand Surgery.

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      1. Scaphoid Fractures - Artificial Intelligence Prediction Tool - Artificial Intelligence.

      Linked Article

      • Erratum
        Journal of Hand SurgeryVol. 47Issue 12
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          In the article by Bulstra and Machine Learning Consortium in the August 2022 issue of The Journal of Hand Surgery (“A Machine Learning Algorithm to Estimate the Probability of a True Scaphoid Fracture After Wrist Trauma”, Vol. 47, No. 8, p. 709-718), one of the Machine Learning Consortium collaborators was listed incorrectly. “Carel (J.C.) Goslings, MD, PhD” should be “J. Carel Goslings, MD, PhD.” The online version of the article has been updated. The authors regret this error.
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