Acute Wrist Trauma Research Articles

Comparative Study of the Diagnostic Value of Panoramic and Conventional Radiography of the Wrist in Scaphoid Fractures

BackgroundScaphoid fractures are the most common type of carpal fractures.ObjectivesThe aim of the study was to compare the diagnostic value of panoramic and conventional radiographs of the wrist in scaphoid fractures.Patients and MethodsThe panoramic and conventional radiographs of 122 patients with acute and chronic wrist trauma were studied. The radiographs were analyzed and examined by two independent radiologist observers; one physician radiologist and one maxillofacial radiologist. The final diagnosis was made by an orthopedic specialist. Kappa test was used for statistical calculations, inter- and intra-observer agreement and correlation between the two techniques.ResultsWrist panoramic radiography was more accurate than conventional radiography for ruling out scaphoid fractures. There was an agreement in 85% or more of the cases. Agreement values were higher with better inter and intra observer agreement for panoramic examinations than conventional radiographic examinations.ConclusionThe panoramic examination of the wrist is a useful technique for the diagnosis and follow-up of scaphoid fractures. Its use is recommended as a complement to conventional radiography in cases with inconclusive findings.

Kienbock's Disease and Scapholunate Dissociation after Acute Wrist Trauma

Scapholunate dissociation is well-known to result from acute wrist trauma [9], or in some cases from chronic crystalline synovitis [1, 6]. The etiology of Kienbock’s disease, or osteonecrosis of the lunate bone, remains unclear, and is likely multifactorial. Trauma may be contributory, although variations in lunate and radial morphology, ulnar-negative variance, lunate vascular pattern, disruption of venous outflow, and systemic conditions such as autoimmune disease and sickle cell anemia have all been associated [5, 12]. Both conditions have been studied extensively as independent pathologies, without any defined relationship. We present a case of Kienbock’s disease accompanied by scapholunate dissociation precipitated by a single traumatic event and followed by simultaneous progression. Both conditions have a variety of treatment options and remain controversial, reflecting a lack of prevailing reliably effective and durable surgical procedures, a lack of high-level evidence, and an uncertain natural history [5, 7, 8, 12]. The combination of these conditions presented unique concerns and was ultimately treated successfully with proximal row carpectomy.

A new definition of wrist sprain necessary after findings in a prospective MRI study

IntroductionWrist injuries with negative X-rays are diagnosed as acute wrist sprains. The prognosis is usually good, but some patients suffer from long-lasting pain and reduced wrist function, probably due to missed diagnosis followed by inappropriate treatment. The aim of this study was to investigate acute wrist sprains with MRI to detect the pathoanatomy of the injury. Patients and methodsThis prospective magnetic resonance imaging (MRI) study included patients between 18 and 49 years, who attended the Accident and Emergency Department (A&E) Bergen, Norway, after sustaining an acute wrist trauma within the previous week. Initial X-rays of the wrist were normal. MRI was done within a median of 1 day (range 0–31 days) after the trauma, 80% within 4 days. The study period lasted from 5 November 2009 to 4 November 2010. ResultsA total of 155 acute MRIs were done, out of which 30 were completely normal. Patients with positive MRI had a median of two (range 0–8) pathological findings. We found 54 fractures and 56 bone bruises, mostly located to the radius followed by the scaphoid, the triquetrum, the capitate and the lunate. There were 73 soft-tissue injuries, which included 15 injuries to the triangular fibrocartilage complex (TFCC) and five scapho-lunate (SL) ligament lesions. ConclusionsWrist sprain is an inaccurate diagnosis. In four out of five patients with normal X-rays, MRI identified pathological findings and a large variety of injuries in different structures. We suggest that wrist sprain should be defined as “occult partial or complete soft tissue (ligament, tendon, muscle) or bony injury in relation to a trauma with negative X-ray”. The MRI findings led to a more differentiated treatment in more than a third of the patients. We recommend that MRI should be considered as a part of an early investigation, especially when the wrist pain does not settle within the first couple of weeks.

The role of plain radiography in paediatric wrist trauma

ObjectivesAcute wrist trauma in children is one of the most frequent reasons for visiting the emergency department (ED). Radiographic imaging in children with wrist trauma is mostly performed routinely to confirm or rule out a fracture. The aim of this study was to determine how many radiographs of the wrist show a fracture in children following wrist trauma.MethodsA retrospective cohort study was performed in three Dutch hospitals from 2009–2010. Data were extracted from patient records and radiographic reports.ResultsOf the 1,223 children who presented at the ED after a wrist trauma, 51 % had a wrist fracture. The peak incidence of having a wrist fracture was at the age of 10 years; 65 % of the children younger than 10 years of age had a wrist fracture. Of all the patients without a wrist fracture, 74 % were older than 10 years of age.ConclusionAlmost half of the paediatric patients with a trauma of the wrist had normal radiographs. The development of a clinical decision rule to determine when a radiograph of the wrist is indicated following acute wrist trauma is needed. This could likely reduce the number of radiographs.Main Messages Fifty-one percent of the children with wrist trauma have a wrist fracture.Peak incidence of having a wrist fracture is at the age of 10 years.Sixty-five percent of the children younger than 10 years of age had a wrist fracture.Of all the patients without a wrist fracture, 74 % were older than 10 years of age.The development of a clinical decision rule to reduce the number of radiographs is needed.

Evaluation of the Diagnostic Performance of Tomosynthesis in Fractures of the Wrist

The purpose of our study was to define the diagnostic value of tomosynthesis compared with standard radiography and CT in wrist injuries. One hundred consecutive patients with acute wrist trauma were investigated with standard radiography, tomosynthesis, and CT. Reference results were those obtained with CT; follow-up monitoring of the patients; and, in some cases, MRI (n=13). Three readers interpreted the findings independently, each using a PACS workstation, and categorized the cases into four groups: fracture of the radius, fracture of the scaphoid, fracture of another bone, and absence of fracture. Fifty-seven percent of the patients had a fracture. The interobserver kappa value varied between 0.54 and 0.59 for standard radiography, between 0.66 and 0.69 for tomosynthesis, and between 0.84 and 0.89 for CT. The sensitivity of standard radiography varied between 61% and 80% and specificity between 65% and 83%. The sensitivity of tomosynthesis ranged between 77% and 87%, and specificity between 76% and 82%. Ranges of sensitivity and specificity for CT were 93-95%, and 86-95%, respectively. The diagnostic value of tomosynthesis is superior to that of standard radiography but inferior to that of CT.

Amsterdam wrist rules: A clinical decision aid

BackgroundAcute trauma of the wrist is one of the most frequent reasons for visiting the Emergency Department. These patients are routinely referred for radiological examination. Most X-rays however, do not reveal any fractures. A clinical decision rule determining the need for X-rays in patients with acute wrist trauma may help to percolate and select patients with fractures.Methods/DesignThis study will be a multi-center observational diagnostic study in which the data will be collected cross-sectionally. The study population will consist of all consecutive adult patients (≥18 years) presenting with acute wrist trauma at the Emergency Department in the participating hospitals.This research comprises two components: one study will be conducted to determine which clinical parameters are predictive for the presence of a distal radius fracture in adult patients presenting to the Emergency Department following acute wrist trauma. These clinical parameters are defined by trauma-mechanism, physical examination, and functional testing. This data will be collected in two of the three participating hospitals and will be assessed by using logistic regression modelling to estimate the regression coefficients after which a reduced model will be created by means of a log likelihood ratio test. The accuracy of the model will be estimated by a goodness of fit test and an ROC curve. The final model will be validated internally through bootstrapping and by shrinking it, an adjusted model will be generated.In the second component of this study, the developed prediction model will be validated in a new dataset consisting of a population of patients from the third hospital. If necessary, the model will be calibrated using the data from the validation study.DiscussionWrist trauma is frequently encountered at the Emergency Department. However, to this date, no decision rule regarding this type of trauma has been created. Ideally, radiographs are obtained of all patients entering one of the participating hospitals with trauma to the wrist. However, this is ethically and logistically not feasible and one could argue that patients, for whom no radiography is required according to their physician, are not suspected of having a distal radius fracture and thus are not part of the domain.Trial registrationThis study is registered at the Netherlands Trial Register (NTR 2544) and was granted permission by the Medical Ethical Committee of the Academic Medical Center Amsterdam on 06-01-2011.

High-Resolution Magnetic Resonance Imaging of Triangular Fibrocartilage Complex Lesions in Acute Wrist Trauma: Image Quality at Different Field Strengths

High-Resolution Magnetic Resonance Imaging of Triangular Fibrocartilage Complex Lesions in Acute Wrist Trauma: Image Quality at Different Field Strengths

High-Resolution Magnetic Resonance Imaging of Triangular Fibrocartilage Complex Lesions in Acute Wrist Trauma: Image Quality at Different Field Strengths

The purposes of this study were to assess the diagnostic capacity of a new high-resolution imaging protocol for the wrist and triangular fibrocartilage complex (TFCC) lesions at 3.0 T and to compare it with our established 1.5-T protocol. Twenty-one patients with an acute wrist trauma were examined at a 3.0-T imaging system and agreed to undergo an additional examination at 1.5 T. Magnetic resonance imaging was performed with 1.5-T (standard wrist coil) and 3.0-T (purpose-build phased-array coil) imaging system, using coronal T1-weighted turbo-spin-echo, proton density-weighted fat-saturated, and coronal and axial contrast-enhanced T1-weighted gradient-echo fat-saturated sequences, with reduced voxel size from 0.50 x 0.50 x 3.0 mm (1.5 T) to 0.20 x 0.20 x 1.5 mm (3.0 T). For qualitative analysis, 2 observers assessed in consensus delineation, image quality, and artifacts in anatomical landmarks (cartilage, TFCC, and TFCC lesion) and ranked them on a 5-point scale from 1 (nondiagnostic) to 5 (optimal). For quantitative analysis, measurements of the contrast-to-noise ratio were obtained between disk and surrounding tissue. All parts of the TFCC and TFCC lesions (n = 14) were seen significantly better at 3.0 T (mean [SD], 4.6 [0.5] vs 2.6 [1.2], P < 0.0001), with higher ranked overall image quality. In 3 cases, TFCC lesions were seen only at 3.0 T. Proton density-weighted fat-saturated sequence had significantly more artifacts at 3.0 T (2.5 [0.6] vs 1.9 [0.5], P < 0.001) in contrast to T1 sequences. Quantitative evaluation showed significantly higher contrast-to-noise ratio for 3.0 T (5.0 [1.1] vs 3.9 [0.9], P < 0.0001). Depiction of anatomy and pathology of the TFCC benefits significantly from 3.0-T imaging when higher signal-to-noise ratio is invested into improved spatial resolution. Especially small lesions of the disk were detected only or better at 3.0 T.

Would it be possible to develop a set of Ottawa wrist rules to facilitate clinical decision making?

Purpose To analyze the possibility of creating clinical decision- making rules to facilitate the assessment of conventional x-rays in acute wrist trauma. Materials and methods This is a prospective observational study. Data was collected on patients treated at the Emergency Department of our hospital further to sustaining acute wrist trauma. 179 patients were included in the study. 46 clinical interview and physical examination variables were used for each patient. Inter-examiner concordance was analyzed for the variables, as well as their statistical association with positive wrist radiology. Data was subsequently analyzed by means of multivariate analysis. Results All 57 patients with positive wrist x-ray images presented with at least one of these characteristics: age equal to or higher than 35, edema of the dorsum of the wrist; limited supination or active radial deviation; and pain or instability on the distal radioulnar drawer test. This clinical decision-making rule is 100% sensitive and 37.7% specific to detect patients with positive wrist x-ray images further to acute trauma. Its use in the sample under study would have reduced the number of x-ray requests by 15.6%. Conclusions A broader study should be undertaken in order to assess the acceptance of a series of clinical decisionmaking criteria for the carrying out of radiographs further to acute wrist trauma.

Acute Wrist Trauma: Value of a Short Dedicated Extremity MR Imaging Examination in Prediction of Need for Treatment

To assess predictive value of a short magnetic resonance (MR) imaging examination in addition to or instead of radiography in patients with acute wrist trauma to identify patients who require additional treatment versus those who do not and can be discharged without further follow-up. Informed consent was obtained from all participating patients; the institutional review board approved the randomized controlled trial and use of data to create prediction models. Of 90 patients (37 female, 53 male; mean age, 40.0 years), 87 with acute wrist trauma were randomized to undergo radiography (n = 43) or radiography and a short MR imaging examination with low-field-strength dedicated extremity MR system (n = 44). Age, sex, trauma mechanism, presence of tenderness of the anatomic snuffbox, radiographic results, MR imaging results, and treatment data were collected. Univariable and multivariable logistic regression analysis was used to create four models for prediction of treatment need. Thirty-six patients had one or more fractures; one patient had a marked soft-tissue lesion. In univariable analysis, age (odds ratio, 1.02; 95% confidence interval: 1.00, 1.05), anatomic snuffbox tenderness (odds ratio, 2.31; 95% confidence interval: 0.90, 5.96), radiographic results (odds ratio, 31.2; 95% confidence interval: 8.90, 109), and positive MR imaging results versus MR imaging not performed (odds ratio, 1.86; 95% confidence interval: 0.57, 6.06) were significantly predictive of treatment need. In multivariable analysis, radiographic results (odds ratio, 24.7; 95% confidence interval: 6.59, 93.1) and positive MR imaging results (odds ratio, 6.28; 95% confidence interval: 1.27, 31.0) were significantly predictive of treatment need. Negative MR imaging results were not significantly predictive (odds ratio, 0.87; 95% confidence interval: 0.20, 3.82). A short MR imaging examination with a low-field-strength MR imaging system following radiography in initial evaluation of patients with acute wrist trauma has additional value in prediction of treatment need; it does not have value in identification of patients who can be discharged without further follow-up.

MR Imaging in Suspected Acute Trauma of Wrist Bones

The purpose of this study was to evaluate the findings of MR imaging compared to plain radiography in acute wrist trauma. Radiography and MR imaging (obtained at 1.5 T) of 67 patients (38 female, 29 male, aged 15-80 years) were analysed by three senior radiologists in a blinded random fashion. One-third (n= 13) of the 37 fractures observed on MR images were missed on the radiographs. The McNemar test indicated significant differences in diagnoses between radiography and MR. We recommend that MR imaging should be considered in the diagnosis of acute wrist trauma when: 1) There is a clear discrepancy between the clinical status and a negative radiography and when splint treatment would increase cost by causing occupational restrictions; and 2) Healing of trauma diagnosed as contusion or distension does not occur within the expected time.

Wrist arthrography after acute trauma to the distal radius: diagnostic accuracy, technique, and sources of diagnostic errors.

The objective of this investigation was to determine the diagnostic accuracy of wrist arthrography in the detection of interosseous ligament disruptions and of triangular fibrocartilage complex (TFCC) lesions in patients after acute wrist trauma and to define the sources of diagnostic error of wrist arthrography after recent trauma. Twenty-two patients with radial fractures after acute wrist trauma underwent arthrography and arthroscopy of the wrist. Arthrography was performed in a standardized manner by two- or three-compartment injection technique. Subsequently wrist arthroscopy was performed within the same session. Image analysis included the evaluation of interosseous carpal ligaments, the TFCC, and the osseous structures. In 22 patients, 11 injuries of the intrinsic ligaments and the TFCC were diagnosed by arthroscopy, of which 9 had been diagnosed correctly with arthrography before surgery. One scaphoid fracture previously missed on conventional radiographs also could be diagnosed by arthrography. Arthrography of the posttraumatic wrist is a valuable tool in the diagnostic evaluation of interosseous carpal ligaments and the TFCC.

Lesions of the scapholunate ligaments in acute wrist trauma--arthroscopic diagnosis and minimally invasive treatment.

The final result of the treatment of distal intra-articular radius fractures depends both on the accuracy of the fracture reduction and on the presence of additional carpal injuries. In particular, lesions of the intrinsic ligaments usually lead to severe degenerative damage of the wrist joint if they are missed primarily. With the introduction of wrist arthroscopy, these tears can be evaluated and treated earlier. Since 1993 arthroscopically assisted treatment has been performed in 23 patients with distal intra-articular fractures of the radius (mainly C-fractures according to the AO classification system or group VII and VIII fractures according to Frykman). Scapholunate (SL) tears were found in 11 patients (47.8%), 7 of whom showed marked instability intraoperatively and were stabilised at the time of surgery.

Suspected scaphoid fractures in skeletally immature patients: application of MRI.

The purpose of our study was to evaluate the MR findings in the wrists of pediatric patients who have sustained acute wrist injuries and to determine if this imaging method yields more information than combined serial radiographs and physical examinations. Eighteen skeletally immature patients (11 boys and 7 girls, age range 8-15 years) who had presented to the emergency room within 2 days following acute wrist trauma underwent serial clinical, radiographic, and MR examinations if there was a suspicion of a scaphoid fracture. Ten patients had a scaphoid abnormality on MR images. Six had fractures and four had regional bone marrow edema. Initially, all but two fractures were radiographically occult, although the other fractures eventually became evident on later studies. Those with marrow edema did not progress to fractures. Obliteration of the scaphoid fat stripe occurred in five patients with a scaphoid fracture and in six patients who did not have a fracture. Dorsal soft tissue swelling occurred in eight patients, five of whom had scaphoid fractures. Seven patients had evidence of extensor tenosynovitis on MRI. A normal initial MR image had a negative predictive value of 100%. Persistent snuffbox pain may represent injury to the scaphoid, extensor tendons, or dorsal soft tissues. An outcome study evaluating the benefits of early application of MR in the pediatric population is warranted.

Scapholunar ligament injuries in acute wrist trauma. Arthroscopic diagnosis and minimally invasive surgery

The final result of the treatment of distal intraarticular radius fractures depends both on the accuracy of the fracture reduction and on the presence or absence of additional carpal injuries. In particular, lesions of the intrinsic ligaments usually cause severe degenerative damage of the wrist joint if they are missed primarily. With the introduction of wrist arthroscopy these tears can be evaluated and treated earlier. Since 1993 arthroscopically assisted treatment has been performed in 23 patients with distal intraarticular fractures of the radius (mainly C fractures according to the AO classification system or group VII and VIII fractures according to Frykman). SL tears have been found in 11 patients (47.8%), 7 of whom showed marked instability and were stabilised at the time of surgery.

Radial avulsion of the triangular fibrocartilage complex in acute wrist trauma: A new technique for arthroscopic repair

The advantages of arthroscopically assisted treatment of intraarticular distal radius fractures, especially the detection of additional carpal lesions, also focus attention on special surgical techniques for operating on these injuries within the same session. When we consider the biomechanical situation, various kinds of triangular fibrocartilage complex (TFCC) lesions, and their arthroscopic aspects, there are probably two possibilities for surgical treatment that are similar to arthroscopic meniscal surgery: resection of flap tears and the refixation of peripherally disinserted TFCC. Avulsions from the ulnar styloid or from the ulnar collateral ligament and the extensor carpi ulnaris tendon can easily and satisfactorily be treated by convenient arthroscopic suture techniques, whereas the reattachment of the triangular disc in the sigmoid notch is very tricky. This problem is solved by a recently developed procedure using the so-called T-Fix-device (Acufex), which provides the possibility of transosseus refixation by closed arthroscopic procedure and therefore guarantees the principle of minimal invasive surgery.

An algorithm for acute wrist trauma A systematic approach to diagnosis

A systematic approach to the acute traumatized wrist is of importance to achieve early diagnosis, with efficient use of advanced imaging modalities. In a 6-month period 641 patients aged 15 years or over were examined using an algorithm for acute wrist trauma in order to secure early and appropriate treatment. In 293 (46%) cases routine radiographic examination supplied sufficient information to establish a fracture diagnosis. All 33 scaphoid fractures (including five scaphoid non-unions) were demonstrated on the initial X-ray examination. In 56 patients (9%) scintigraphy proved useful for selecting cases in need of further radiographic examination. Among 31 patients with focal activity on bone scintigraphy, CT and/or tomography revealed eight distal radial fractures, one fracture of the ulnar styloid, and eight fractures of carpal bones. Fractures were revealed using tomography and/or “hot spot views” in patients with negative CT examinations suggesting that further examinations should be performed in cases with increased focal activity on bone scintigraphy and a negative CT examination.

Epidemiology of acute wrist trauma.

Epidemiological data on wrist injuries in a population can be used for planning by applying them to criteria for care and thus deriving estimates of provisions for care according to currently desirable standards. In a 1-year study all patients > or = 15 years with acute wrist trauma and treated in the emergency room were examined according to an algorithm until a diagnosis was established. The overall incidence of wrist trauma was 69 per 10,000 inhabitants per year. Incidence of wrist trauma requiring x-ray examination was 58 per 10,000 per year. The incidence of distal radius fractures was 27 per 10,000 per year (males, 16 per 10,000, females, 37 per 10,000 per year). In order to evaluate the completeness (defined as the proportion of patients with wrist injuries seen in the emergency room to all patients with wrist injuries in the catchment area) of the hospital-based data an analysis was performed using data from a population-based study. A completeness rate of 0.56 (95% confidence interval: 0.31-0.78) was found. An x-ray had been taken for all patients reporting a fracture thus justifying the use of fractures as an incidence measure when comparing groups of patients with wrist trauma.

The value of soft tissue signs in wrist trauma

A retrospective study of the wrist radiographs of 1453 patients presenting with acute wrist trauma was undertaken in order to assess the value of soft tissue signs. A total of 773 radiographs which were judged to be normal were used to evaluate the normal pronator quadratus fat stripe. The distance of the normal pronator fat stripe from the radius was shown to be significantly lower in females than in males and increased with age. The increase with age was greater in males. Although most fractures were associated with some soft tissue abnormality, certain fractures, especially greenstick fractures in children, had normal soft tissue planes. Only 4% of the wrists examined had soft tissue abnormalities with no visible fracture. The presence of soft tissue signs should therefore be considered with suspicion when evaluating wrist radiographs in trauma, but the absence of signs does not necessarily exclude a fracture.