The small sample size of the studies and the observed heterogeneity make generalisable conclusion difficult. In conclusion, both tuning fork methods have some discrimination ability, but current techniques are not sufficiently reliable or accurate to rule in or out fractures and currently should have only limited use in clinical practice. It is also unclear whether swelling or bruising in the area of the injury might affect the results.Ī systematic review, 11 which examined a variety of methods for the diagnosis of stress fractures, included only two of the six studies we used in this review. Both types of tuning fork tests seem to be more accurate in diagnosing transverse fractures than other types of fractures. It is unclear whether a discontinuity of the cortical bone is required in order to give a positive test result. Timing may also affect the accuracy of the test.Ī mineralised callus where fracture healing has been initiated might not be identified by these tests. A bone scan, however, would show an increased activity in the fractured area. Lesho 9 suggests that in the early stages, stress fractures might not be identified by the tuning fork test, because the bone shell is still more or less intact. Wilder et al 10 compared different frequencies and found a higher induction of fracture pain using 256 Hz, but pain also occurred in patients without fractures resulting in a low specificity.īased on the results in this review, the tuning fork test was less accurate for stress fractures than other types of fractures, but a number of features of this type of injury may modify the accuracy. The low inter-tester reliability suggests that the techniques would benefit from standardisation and training. The reasons for this variation in accuracy are unclear, but may be related to both the way the test is performed or to characteristics of the injuries and fractures. The specificity is particularly heterogeneous, potentially resulting in a high proportion of false-positive test results. However, the estimated sensitivity (ranging from 75% to 100%) is not sufficient to be relied on to rule out fractures based on a negative test. Two forms of tuning fork test, one based on pain induction and the other on sound transmission, showed modest diagnostic accuracy with some ability to rule out fractures. 3 4 We appraised each article using the QUADAS-2 tool. 95% CIs for sensitivity and specificity were calculated with the Wilson score method and 95% CIs for positive and negative likelihood ratios were calculated with the method described by Simel et al. Wherever possible, we used the raw data to construct 2×2 tables. The primary outcome measure of interest was the accuracy of the test as measured by its sensitivity and specificity. We resolved disagreements through discussion with the third author (PG). In the case of duplicate publication, we selected the most complete version of the study. Two review authors (KM and JD) independently reviewed each paper for inclusion according to the predefined inclusion criteria, rated the study quality and then extracted relevant data. The titles and abstracts of all search results were screened by two authors (KM and JD) and full manuscripts for all potential relevant papers were obtained. We selected studies in a two-stage process. The aim of this review was to identify the techniques used to diagnose fractures using a tuning fork and assess all studies of the diagnostic accuracy of tuning fork tests for the presence of fracture. Using a stethoscope to listen to the sound over a bony prominence proximal to the fracture site, the fracture is detected by a reduction in the sound conducted along the bone compared to the unaffected limb. The second method uses a vibrating tuning fork placed over a bony prominence distal to the fracture site. 2 The pain stops or decreases with the removal of the tuning fork. Because the periosteum is heavily innervated, mechanical vibration over a fracture site stimulates the overlying periosteum, causing pain. The first method uses a vibrating tuning fork placed directly over, or closely proximal to the suspected fracture site. Two methods of using tuning forks to detect fracture(s) have been developed. One test which was proposed at least 60 years ago is the use of a tuning fork. Other clinical tests for fracture may then assist in decision making. Although imaging for suspected fractures is generally cheap and readily accessible, there are situations such as remote settings, where imaging is not readily available.
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