Twelve cohort studies, eight prospective (three also consecutive) and four retrospective chart reviews (n=7,147) were included. Sample size ranged between 71 and 2,404 patients. Included studies met between four and seven items using the QUADAS tool. Reporting of details on the index tests and the reference standard was poor. Most studies provided index test results only for those patients who received the reference standard.
None of the signs or symptoms evaluated showed consistently good performance for ruling in or ruling out fracture.
Age showed some association with fracture: age over 50 had some potential to rule in vertebral fracture (LR+ 2.2, 95% CI 1.4 to 2.8 and 1.7, 95% CI 1.5 to 1.9; two studies) and had some potential to rule out fracture (LR- 0.34, 95% CI 0.12 to 0.75 and 0.35, 95% CI 0.22 to 0.54). Women were also at slightly increased risk of fracture, but this was insufficient to be used to rule in (LR+ 1.3, 95% CI 1.1 to 1.4 and 2.3, 95% CI 1.1 to 4.3) or rule out fracture (LR- 0.65, 95% CI 0.45 to 0.90 and 0.67, 95% CI 0.37 to 0.97; two studies).
Studies on trauma reported inconsistent results that suggested slight to good potential for ruling in fracture (LR+ ranged from 1.7 to 14.4) and poor to excellent performance in ruling out fracture (LR- ranged from 0.00 to 0.78). Only two studies found that features related to trauma could be used to rule in a diagnosis of fracture (LR+ 12.8 and 14.4); one of these studies reported some potential for ruling out fracture (LR- 0.37) and the other suggested poor performance (LR- 0.73).
The presence of pain and/or tenderness showed inconsistent performance for ruling in or ruling out fracture. Use of corticosteroids, altered consciousness and presence of other injuries also showed poor performance both for ruling in and ruling out a diagnosis of fracture.
Sensitivity and specificity were reported in the review.