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Study Quality
1. Larsen CF, Lauritsen J. Epidemiology of acute wrist trauma. Int J Epidemiol 1993; 22(5):911-916. Observational-Dx 865 patients with acute wrist trauma Aims of the study were: 1) To determine the age and sex-specific incidence of wrist trauma and compare data with other studies; 2) an evaluation of the completeness (defined as the proportion of patients with wrist injuries seen in the emergency room to all patients with wrist injuries in the community) of hospital-based data on wrist trauma, and 3) to evaluate the correlation between the incidence of distal radius fractures and weather conditions. 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% CI: 0.31-0.78) was found. 3
2. Wallmann HW. Overview of Wrist and Hand Injuries, Pathologies, and Disorders: Part 2. Home Health Care Management & Practice 2010; 23(2):146-148. Review/Other-Dx N/A Review physical examination and address an overview of some of the common injuries, pathologies, and disorders of the wrist and hand complex that may be seen in a hospital or outpatient clinical settings. No results stated in abstract. 4
3. Hyland-McGuire P, Guly HR, Hughes PM. Double take--fracture fishing in accident and emergency practice. J Accid Emerg Med. 1997; 14(2):84-87. Review/Other-Dx 55 patients To investigate conditions where, after initially negative plain x rays following trauma, there subsequently proves to be fracture, and to explore ways in which the management might be improved. 55 cases were identified: 41 fractures were identified on subsequent plain x ray, 6 on bone scan, 6 on CT scan, and 2 on MRI scan. The commonest regions involved were the wrist, pelvis/hip, ankle/foot, and leg. Follow-up had not been arranged at the initial attendance in 17 instances and between 2 and 135 days were required for definitive fracture recognition. All but 9 patients required alteration in treatment because of fracture detection. 4
4. Moraux A, Vandenbussche L, Demondion X, Gheno R, Pansini V, Cotten A. Anatomical study of the pisotriquetral joint ligaments using ultrasonography. Skeletal Radiol. 2012; 41(3):321-328. Review/Other-Dx 8 cadavers To demonstrate that US may allow a precise assessment of the primary stabilizers of pisotriquetral joint (pisohamate, pisometacarpal, and ulnar pisotriquetral ligaments). At dissection, the metal markers were located in the ligaments or immediately adjacent to them, confirming that they were correctly depicted using US. The three ligaments could also be identified in each volunteer. The optimal positioning of the probe and the dynamic maneuvers of the wrist allowing the strain of these ligaments could be defined. No significant changes in the appearance and thickness of the ligaments could be observed. 4
5. De Smet AA, Doherty MP, Norris MA, Hollister MC, Smith DL. Are oblique views needed for trauma radiography of the distal extremities? AJR Am J Roentgenol.1999; 172(6):1561-1565. Observational-Dx 1,461 consecutive radiographic examinations To determine whether the oblique view uniquely revealed abnormalities or clarified findings when it was obtained along with routine frontal and lateral radiographs. The examinations included 421 with abnormal findings, 34 with equivocal findings, and 1,006 with normal findings. The addition of the oblique view changed the interpretation in 70 (4.8%) of the 1,461 examinations. Of these changed interpretations, 39 were changed from equivocal to either positive or negative, 3 from positive to negative, and 28 from negative to positive. Addition of the oblique view increased diagnostic confidence: The percentage of examinations scored as having probably normal, equivocal, and probably abnormal findings decreased from 13.9% with two views to 8.4% with 3 views (P<.0001). The oblique view was equally valuable in the ankle, foot, toe, wrist, hand, finger, and thumb. 3
6. Gilbert TJ, Cohen M. Imaging of acute injuries to the wrist and hand. Radiol Clin North Am. 1997; 35(3):701-725. Review/Other-Dx N/A To review the basic characteristics of common fractures and dislocations in the hand and wrist. There is increasing recognition that fractures and dislocations of the hand and wrist can result in long-term pain and dysfunction. 4
7. Russin LD, Bergman G, Miller L, et al. Should the routine wrist examination for trauma be a four-view study, including a semisupinated oblique view? AJR Am J Roentgenol. 2003; 181(5):1235-1238. Observational-Dx 54 wrist examinations To document the relative sensitivity of each of the four views for fracture detection and to assess whether it is beneficial to make the routine radiographic examination a 4-view study. The number of ulnar fractures reported by the four reviewers in the 54 examinations ranged from 15 to 20 (average, 18.3) The number of navicular fractures ranged from 1 to 6 (average, 3.8). The reviewers found fractures of the ulna and navicular bone more readily on the posteroanterior and posteroanterior oblique views than on the lateral and semisupinated oblique views They identified few fractures of the other carpal bones and metacarpals in the 54 examinations. 3
8. Lohman M, Kivisaari A, Vehmas T, et al. MR imaging in suspected acute trauma of wrist bones. Acta Radiol. 1999; 40(6):615-618. Observational-Dx 67 patients To evaluate the findings of MRI compared to plain radiography in acute wrist trauma. One-third (n=13) of the 37 fractures observed on MRI were missed on the radiographs. The McNemar test indicated significant differences in diagnoses between radiography and MRI. 2
9. Mack MG, Keim S, Balzer JO, et al. Clinical impact of MRI in acute wrist fractures. Eur Radiol. 2003; 13(3):612-617. Observational-Dx 54 patients (56 wrists) To determine clinical impact of MRI in traumatized wrists with normal or suspicious radiographs and clinical findings. In 31/56 wrists MRI findings resulted in a change of diagnosis. There were false-positive diagnoses on plain radiographs in nearly one-half (n=25) of the patients. False-negative diagnoses on plain radiographs resulted in 6 cases. MRI detected additional injuries of soft tissue in more than one third (n=20). In 22/56 wrists the period of immobilization could be shortened or ended, in 12/56 it was prolonged, and in 3/56 a surgical intervention was necessary. In 19 wrists MRI had no therapeutic consequences. 3
10. Nikken JJ, Oei EH, Ginai AZ, et al. Acute wrist trauma: value of a short dedicated extremity MR imaging examination in prediction of need for treatment. Radiology. 2005; 234(1):116-124. Experimental-Dx 87 patients To assess predictive value of a short MRI examination in addition to or instead of radiography in patients with acute wrist trauma to identify patients who require additional treatment vs those who do not and can be discharged without further follow-up. 87 patients with acute wrist trauma randomized to radiography (n=43) or radiography and a short MRI examination with low-field-strength dedicated E-MRI (n=44). 36 patients had one or more fractures; one patient had a marked soft-tissue lesion. In univariable analysis, age (OR, 1.02; 95% CI: 1.00, 1.05), anatomic snuffbox tenderness (OR, 2.31; 95% CI: 0.90, 5.96), radiographic results (OR, 31.2; 95% CI: 8.90, 109), and positive MRI results vs MRI not performed (OR, 1.86; 95% CI: 0.57, 6.06) were significantly predictive of treatment need. In multivariable analysis, radiographic results (OR, 24.7; 95% CI: 6.59, 93.1) and positive MRI results (OR, 6.28; 95% CI: 1.27, 31.0) were significantly predictive of treatment need. Negative MRI results were not significantly predictive (OR, 0.87; 95% CI: 0.20, 3.82). 2
11. Remplik P, Stabler A, Merl T, Roemer F, Bohndorf K. Diagnosis of acute fractures of the extremities: comparison of low-field MRI and conventional radiography. Eur Radiol. 2004; 14(4):625-630. Observational-Dx 78 (41 fractures, 37 without fracture) patients To compare low-field MRI (0.2 T) and conventional radiography for the detection of acute fractures of the distal part of the extremities. The MRI and conventional radiography revealed a accuracy of 81.4% and of 79.5%, respectively, in the detection of acute fractures. The diagnostic accuracy of MRI to detect fractures in the hand and forefoot proved to be significantly inferior to conventional X-ray examinations. On the other hand, MRI achieved a better accuracy for the examination of bones near a large joint. The interobserver variability for both methods was rated as moderate. In ROC analysis both methods were rated as good. There was no statistical difference of the accuracy between low-field MRI and conventional radiography in the detection of acute fractures of the distal part of the extremities. 3
12. Nikken JJ, Oei EH, Ginai AZ, et al. Acute peripheral joint injury: cost and effectiveness of low-field-strength MR imaging--results of randomized controlled trial. Radiology. 2005; 236(3):958-967. Experimental-Dx 472 patients: 237 allocated to MRI strategy (MRI plus radiography), and 235 allocated to radiography alone To assess prospectively if a short imaging examination performed with low-field-strength dedicated MRI in addition to radiography is effective and cost saving compared with the current diagnostic imaging strategy (radiography alone) in patients with recent acute traumatic injury of the wrist, knee, or ankle. In the intervention group, quality of life for patients with knee injuries was significantly higher during the first 6 weeks, and time to completion of diagnostic workup was significantly shorter (mean, 3.5 days for intervention group vs 17.3 days for reference group). The number of additional diagnostic procedures was significantly lower in the intervention group vs the reference group (9 vs 35, respectively) for patients with knee injuries. Patients with knee injuries showed the largest difference in costs (intervention group, €1820 [$1,966]; reference group, €2231 [$2,409]) owing to a reduction in productivity loss. Costs were higher in patients with wrist injuries and almost equal in patients with ankle injuries. All cost differences, however, were not significant. 1
13. Kiuru MJ, Haapamaki VV, Koivikko MP, Koskinen SK. Wrist injuries; diagnosis with multidetector CT. Emerg Radiol. 2004; 10(4):182-185. Review/Other-Dx 38 patients To assess acute-phase MDCT findings in wrist injuries. MDCT revealed 56 fractures and 7 dislocations in 29 patients. In 9 patients (24%) MDCT findings were normal. 11 patients (29%) underwent surgical procedures. The main injury mechanism was a fall (58%). In 33 cases the primary radiograph was available. Compared to primary radiographs, MDCT revealed 9 occult fractures, mainly in small carpal bones. In 14 cases a suspected fracture (of the scaphoid in 7 cases) was ruled out by MDCT. Due to high-quality two-dimensional reformatting, MDCT examinations were not dependent on the wrist's position in the CT gantry. In the comparison with radiography, MDCT detected occult fractures and ruled out suspected fractures, both mainly in the small carpal bones. High-quality two-dimensional reformats gave significant information about the fracture anatomy. MDCT provides fast and valuable information in assessing complex wrist fractures or when the primary radiograph is equivocal. 4
14. Tiel-van Buul MM, van Beek EJ, Dijkstra PF, Bakker AJ, Broekhuizen TH, van Royen EA. Significance of a hot spot on the bone scan after carpal injury--evaluation by computed tomography. Eur J Nucl Med. 1993; 20(2):159-164. Observational-Dx 18 patients Prospective study was performed to confirm scintigraphically suspected fractures in the carpus by means of CT. In 18 patients, 21 out of 22 carpal hot spots on bone scintigraphy could be radiologically confirmed as a fracture. The diagnosis was missed by CT scan in three patients with proven fractures on plain radiographs. 2
15. Rodriguez-Merchan EC. Management of comminuted fractures of the distal radius in the adult. Conservative or surgical? Clin Orthop Relat Res. 1998; (353):53-62. Review/Other-Dx N/A Discuss treatment of distal radius fractures and determinants of outcomes. Early recognition and treatment of distal radioulnar joint injuries associated with fractures of the distal radius are paramount to reduce the incidence of painful sequelae and functional deficits. 4
16. Harness NG, Ring D, Zurakowski D, Harris GJ, Jupiter JB. The influence of three-dimensional computed tomography reconstructions on the characterization and treatment of distal radial fractures. J Bone Joint Surg Am. 2006; 88(6):1315-1323. Observational-Dx 30 patients, 4 observers To determine whether 3D images improve the reliability and accuracy of fracture characterization and, secondarily, whether they influence the choice of treatment as compared with 2D images. 3D CT improved the intraobserver agreement, but not the interobserver agreement, regarding the presence of coronal plane fracture lines and central articular fragment depression. 3D CT improved both the intraobserver and the interobserver agreement regarding the presence of articular commination. Interobserver agreement increased when 3D CT was used to determine the exact number of articular fracture fragments. The sensitivity and accuracy of identifying specific fracture characteristics (as compared with intraoperative findings) improved when 3D imaging was used in conjunction with 2D imaging as compared with 2D imaging alone. The addition of 3D CT to 2D CT influenced treatment recommendations, resulting in a significantly greater number of decisions for an open approach (P<0.05) and combined dorsal and volar exposure (P<0.001). 2
17. Goldfarb CA, Rudzki JR, Catalano LW, Hughes M, Borrelli J, Jr. Fifteen-year outcome of displaced intra-articular fractures of the distal radius. J Hand Surg Am. 2006; 31(4):633-639. Observational-Dx 16 patients To evaluate the same cohort at an average of 15 years after surgery to evaluate the effect of additional time on both function and radiographic appearance. The authors re-evaluated 16 of the original 21 patients. The average maximum gap displacement on plain radiographs was 2.1 mm (range, 0.0-15.0 mm, lateral view) and on CT images was 4.9 mm (range, 0.7-17.3 mm, axial view). The average maximum step displacement on plain radiographs was 0.9 mm (range, 0.0-6.4 mm, lateral view) and on CT images was 1.2 mm (range, 0.0-6.0 mm, sagittal view). More reproducible values determining step and gap displacement were obtained when the arc method of measurement was used on CT scans (ICC values, .69-.97) as compared to the longitudinal axis method for plain radiographs (ICC values, .30-.50). For measured displacements of 2 mm or more, the data demonstrated poor correlation between measurements made on CT images and those made on plain radiographs (gap or step displacement >2 mm, K = 0.21; step displacement >2 mm, K = 0.21). Thirty percent of measurements from plain radiographs significantly underestimated or overestimated displacement compared to CT scan measurements. 2
18. Cole RJ, Bindra RR, Evanoff BA, Gilula LA, Yamaguchi K, Gelberman RH. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal radius: reliability of plain radiography versus computed tomography. J Hand Surg Am. 1997; 22(5):792-800. Observational-Dx 19 acute intra-articular distal radius fractures To evaluate the reliability of plain radiography vs CT for the measurement of small (<5 mm) intra-articular displacements of distal radius fracture fragments. CT showed more intra-articular displacements than radiographs. CT measurements of gap and step-off more reproducible than radiographic measurements. For displacements >2 mm, poor correlation between CT and radiographs. 2
19. Rozental TD, Bozentka DJ, Katz MA, Steinberg DR, Beredjiklian PK. Evaluation of the sigmoid notch with computed tomography following intra-articular distal radius fracture. J Hand Surg Am. 2001; 26(2):244-251. Review/Other-Dx 20 consecutive distal radius fractures To characterize the patterns of sigmoid notch involvement in displaced intra-articular distal radius fractures. Plain radiographs revealed fracture extension into the sigmoid notch in only 7 cases (35%) and the CT scans demonstrated fracture extension into the sigmoid notch in 13 cases (65%). Of the 13 fractures with sigmoid notch involvement, 9 (69%) were displaced and 4 (31%) were nondisplaced. Sigmoid notch articular step-off (n=7) and gapping (n=9) were detectable on the CT scans but not on the x-rays. 4
20. Catalano LW, 3rd, Barron OA, Glickel SZ. Assessment of articular displacement of distal radius fractures. Clin Orthop Relat Res. 2004; (423):79-84. Review/Other-Dx N/A Discuss measurement, imaging, and effect of articular incongruence in distal radius fractures. Tomography is an effective method for postoperative evaluation of fractures immobilized in splints or casts. The role of MRI in assessing intra-articular distal radius fractures is limited to confirming injuries to carpal ligaments or the triangular fibrocartilage complex. 4
21. Spence LD, Savenor A, Nwachuku I, Tilsley J, Eustace S. MRI of fractures of the distal radius: comparison with conventional radiographs. Skeletal Radiol. 1998; 27(5):244-249. Review/Other-Dx 21 consecutive inpatients To compare the evaluation of fractures of the distal radius with MRI and conventional radiographs. To demonstrate the ability of MRI to detect unsuspected soft tissue derangement accompanying this common injury. Of 21 patients with fractures of the distal radius, 20 had extension to the radiocarpal articulation, 14 had distal radio-ulnar joint extension and 5 had avulsion of the ulnar styloid. Occult carpal bone fractures accompanying fracture of the distal radius were identified in two patients: one of the capitate and the other of the second metacarpal base. 10 patients (48%) had associated soft tissue injury: 6 patients had scapholunate ligament rupture, 2 patients had disruption of the triangular fibrocartilage, 1 patient had extensor carpi ulnaris tenosynovitis and 1 patient had a tear of a dorsal radiocarpal ligament. Of 5 patients with ulnar styloid avulsions, none had evidence of triangular fibrocartilage tears. 4
22. Mino DE, Palmer AK, Levinsohn EM. Radiography and computerized tomography in the diagnosis of incongruity of the distal radio-ulnar joint. A prospective study. J Bone Joint Surg Am. 1985; 67(2):247-252. Review/Other-Dx 15 patients Prospective evaluation of patients with acute or chronic pain in the distal radio-ulnar joint, using both standardized radiographs and CT in the diagnosis of incongruity of the distal radio-ulnar joint. When pain or cast immobilization prevented optimum positioning of the wrist for radiography, or when a deformity of the distal end of the radius was present, CT gave a more accurate determination of the congruency of the joint. 4
23. Wechsler RJ, Wehbe MA, Rifkin MD, Edeiken J, Branch HM. Computed tomography diagnosis of distal radioulnar subluxation. Skeletal Radiol. 1987; 16(1):1-5. Review/Other-Dx 8 patients To evaluate the distal radio-ulnar joint with CT. Four patients shown to have distal radio-ulnar joint subluxation by CT. 4
24. Szabo RM. Distal radioulnar joint instability. J Bone Joint Surg Am. 2006;88(4):884-894. Review/Other-Dx N/A To review the anatomy, classification, and examination of radioulnar joint instability. No results stated. 4
25. Daffner RH, Emmerling EW, Buterbaugh GA. Proximal and distal oblique radiography of the wrist: value in occult injuries. J Hand Surg Am. 1992; 17(3):499-503. Review/Other-Dx N/A Review proximal and distal oblique radiography of the wrist and their value in occult injuries. Scaphoid and capitate fractures may be better demonstrated. 4
26. Groves AM, Cheow H, Balan K, Courtney H, Bearcroft P, Dixon A. 16-MDCT in the detection of occult wrist fractures: a comparison with skeletal scintigraphy. AJR Am J Roentgenol. 2005; 184(5):1470-1474. Observational-Dx 51 patients To compare the measured uptake of Tc-99m-MDP in those scaphoid fractures seen on both 16-MDCT and scintigraphy, with those seen only on scintigraphy. 23 fractures were identified on scintigraphy of which 16 were also detected on CT (concordant). In 7 cases the fracture was not seen on CT, even in retrospect (discordant). In the discordant cases, follow-up radiographs and MRI (where available) also failed to demonstrate a fracture. The mean fracture count to background bone activity ratio averaged 7.7 (range 3.2-18.5) for concordant fractures and 3.8 (range 1.7-5.3) for discordant fractures (t-test P=0.04). The maximum fracture count to background bone activity ratio averaged 12.7 (range 4.3-27.7) for concordant fractures and 6.3 (range 2.6-9.5) for discordant fractures (t-test P=0.03). 3
27. Groves AM, Cheow HK, Balan KK, Bearcroft PW, Dixon AK. 16 detector multislice CT versus skeletal scintigraphy in the diagnosis of wrist fractures: value of quantification of 99Tcm-MDP uptake. Br J Radiol. 2005; 78(933):791-795. Observational-Dx 51 patients To assess the potential use of MDCT in the detection of occult scaphoid fractures. CT was positive for wrist fracture in 14 (27.4%) of 51 patients and skeletal scintigraphy in 23 (45.1%) of 51 patients. After retrospective review, there were 7 discrepant cases (13.7%), all of which were positive for wrist fracture on scintigraphy but negative on CT. 4/7 patients with discordant findings underwent further radiography at 6 weeks, which did not show fracture. 3
28. Foex B, Speake P, Body R. Best evidence topic report. Magnetic resonance imaging or bone scintigraphy in the diagnosis of plain x ray occult scaphoid fractures. Emerg Med J. 2005;22(6):434-435. Review/Other-Dx 4 articles with best evidence To establish whether MRI or bone scintigraphy is better at identifying scaphoid fractures not apparent on plain x-rays. MRI is the investigation of choice in the clinically suspected scaphoid fracture after negative initial and 10-14 day follow up x-rays. A bone scan is a reasonable alternative in patients with claustrophobia. 4
29. Groves AM, Kayani I, Syed R, et al. An international survey of hospital practice in the imaging of acute scaphoid trauma. AJR Am J Roentgenol. 2006; 187(6):1453-1456. Review/Other-Dx 200 surveys (105 returned) To determine imaging strategies used by differing institutions in cases of suspected scaphoid fractures with initial normal radiographs. The number of scaphoid radiographic views varied from two to six. Before second-line investigations were initiated, repeat radiographs were usually performed in 76/105 hospitals. In 29 hospitals, other imaging techniques were used without further radiography. The usual second-line investigation was MRI in 31/105, CT in 19/105, and scintigraphy in 14/105. Further protocols included CT or MRI in 10/105, CT or scintigraphy in 6/105, scintigraphy or MRI in 6/105, CT then MRI (if CT was negative) in 1/105, CT and scintigraphy in 1/105, and scintigraphy then CT (if positive) in 1/105. There was equal preference among MRI, CT, and scintigraphy in 10/105 centers, and clinical examination and radiographs were used alone in 6/105. 4
30. Berna JD, Chavarria G, Albaladejo F, et al. Panoramic versus conventional radiography of scaphoid fractures. AJR Am J Roentgenol. 2004; 182(1):155-159. Observational-Dx 90 patients To compare the diagnostic value of panoramic and conventional radiography in the detection of fractures of the carpal scaphoid bone. Panoramic radiography of the wrist was superior to conventional radiography in ruling out scaphoid fractures (74%, 20/27) in patients with suspicious findings on conventional radiography; revealed more cases of scaphoid fractures (21.4%, 12/56); and revealed more cases of delayed union (n=2), nonunion (n=3), and union (n=3). Agreement values were higher, with better inter- and intraobserver agreement, for the panoramic examinations than for the conventional radiographic examinations. 3
31. Breitenseher MJ, Metz VM, Gilula LA, et al. Radiographically occult scaphoid fractures: value of MR imaging in detection. Radiology. 1997; 203(1):245-250. Observational-Dx 42 patients To evaluate the diagnostic value of MRI in patients with clinical suspicion of scaphoid fractures and normal initial plain radiographs. MRI depicted occult fractures of the scaphoid bone in 14 patients (33%), the capitate bone in 4 (10%), the trapezium in 1 (2%), and the distal radius in 2 (5%). All wrist fractures were detected with a combination of short tau inversion recovery and T1-weighted spin-echo sequences. The sensitivity and specificity for detection of radiographically occult fractures of the wrist were 100% each for the first and 95% and 100%, respectively, for the second radiologist with an almost perfect interobserver agreement (K = 0.953). 2
32. Bretlau T, Christensen OM, Edstrom P, Thomsen HS, Lausten GS. Diagnosis of scaphoid fracture and dedicated extremity MRI. Acta Orthop Scand. 1999; 70(5):504-508. Observational-Dx 47 patients To evaluate the value of dedicated E-MRI in patients with clinical suspicion of a scaphoid fracture and normal initial radiographs. E-MRI detected occult fractures of the scaphoid in 9 patients, and of the distal radius in a further 6 patients. All these fractures were confirmed at follow-up radiographs. Furthermore, E-MRI revealed a fracture of the capitate bone in 1 patient, and of the triquetrum in 2 patients, and in 8 patients, bone bruise in 1 or more of the carpal bones. However, these fractures and bone lesions could not be confirmed by the follow-up radiographs. The agreement between the two examiners was high (kappa = 0.8) for E-MRI detection of fractures. 2
33. Brydie A, Raby N. Early MRI in the management of clinical scaphoid fracture. Br J Radiol. 2003; 76(905):296-300. Review/Other-Dx 195 patients To determine clinical impact of 0.25-T dedicated E-MRI for radiographically-occult scaphoid fractures. 37 scaphoid fractures (19%), 28 distal radius fractures (14%), 9 fractures of other carpal bones (5%) and 119 studies with no fracture. The management of 180 patients (92%) was altered as a result of the MRI scan. Occult fractures are present in almost two fifths of patients with suspected scaphoid fracture and normal initial plain radiographs. Half of these are scaphoid fractures. 4
34. Hauger O, Bonnefoy O, Moinard M, Bersani D, Diard F. Occult fractures of the waist of the scaphoid: early diagnosis by high-spatial-resolution sonography. AJR Am J Roentgenol. 2002; 178(5):1239-1245. Observational-Dx 54 patients To evaluate the diagnostic accuracy of high-spatial-resolution US in the diagnosis of occult fractures of the waist of the scaphoid. Follow-up examinations proved fracture of the scaphoid waist in 5 patients. In all patients, diagnosis of fracture was suspected on initial US showing cortical disruption associated with soft-tissue abnormalities. There was one false-positive finding and no false-negative results. Using cortical disruption as a diagnostic criterion, the sensitivity, specificity, and accuracy of high-resolution US for the depiction of scaphoid fracture were 100%, 98%, and 98%, respectively. Using soft-tissue abnormalities alone as a criterion, the sensitivity, specificity, and accuracy of high-resolution US were 100%, 65%, and 68%, respectively. The overall prevalence of occult fracture was 9%, ranging from 3.7% for low suspicion to 27% for high suspicion of fracture. 3
35. Hodgkinson DW, Nicholson DA, Stewart G, Sheridan M, Hughes P. Scaphoid fracture: a new method of assessment. Clin Radiol. 1993; 48(6):398-401. Observational-Dx 78 patients To evaluate the value of color flow Doppler US in patients with suspected acute carpal scaphoid fractures. There were 61 patients with no evidence of a scaphoid fracture or other fracture and they were assumed to have sustained a soft tissue injury. In this group those with a scaphoid index >30% did not spend longer in plaster (P=0.52; >30%, median 11 days and range 0-41 days; <30%, median 12 days and range 0-80 days) but did spend longer to discharge (P=0.17; >30%, median 28 days and range 10-74 days; <30%, median 16 days and range 8-109 days), the latter value was not significant. 12 patients with subsequent scaphoid fractures were identified with US. 2
36. Hunter JC, Escobedo EM, Wilson AJ, Hanel DP, Zink-Brody GC, Mann FA. MR imaging of clinically suspected scaphoid fractures. AJR Am J Roentgenol. 1997; 168(5):1287-1293. Observational-Dx 36 patients To evaluate usefulness of MRI in revealing occult fractures of scaphoid in patients with clinically suspected acute scaphoid fractures who have normal or equivocal findings on radiographs. MRI revealed 22 occult fractures in 20 patients. 13/22 fractures were in the scaphoid bone and 9 were in the distal radius. On MRI, 16 patients had no evidence of fracture. Follow-up radiographs were available in 14/20 patients who had occult fracture revealed by MRI. 11/13 occult fractures of the scaphoid bone were followed-up (2 were lost to follow-up), and 10/11 showed signs of healing. 5/9 lesions of the distal radius were followed up and 3 of these showed evidence of healing fracture. Three patients without MR evidence of a fracture had follow-up radiographs that showed no fracture. Three patients had findings consistent with bone contusion on MRI; in 2 patients, the contusion was associated with other fractures and in one patient, the contusion was isolated. 3
37. Tiel-van Buul MM, Broekhuizen TH, van Beek EJ, Bossuyt PM. Choosing a strategy for the diagnostic management of suspected scaphoid fracture: a cost-effectiveness analysis. J Nucl Med. 1995; 36(1):45-48. Review/Other-Dx 160 patients To assess the cost-effectiveness of various strategies for the diagnostic management of clinically suspected scaphoid fracture. A decision-analytic model was built to evaluate three strategies and to compare them with a (clairvoyant) reference diagnostic management strategy. Overall costs were 273.7, 317.7 and 316.1 European Currency Units (ECU) for Strategies A, B and C, respectively (1 ECU = 1.15 U.S. dollar). Strategy B led to the longest average period of immobilization (8.6 weeks), while Strategy A resulted in the highest nonunion rate (4.7%). The costs per nonunion saved for the additional use of bone scintigraphy (Strategy C) was ECU 2618 when compared to Strategy A. 4
38. Bayer LR, Widding A, Diemer H. Fifteen minutes bone scintigraphy in patients with clinically suspected scaphoid fracture and normal x-rays. Injury. 2000; 31(4):243-248. Review/Other-Dx 40 patients To evaluate a rapid version of bone scintigraphy with images produced 15 minutes after intravenous injection of Tc-99m-MDP. The authors found 8 fractures of the scaphoid bone and 13 fractures of other carpal bones. In 5 cases the images were inconclusive. At follow-up 6 months to 2 years later authors found no patients with non-union. 4
39. Fowler C, Sullivan B, Williams LA, McCarthy G, Savage R, Palmer A. A comparison of bone scintigraphy and MRI in the early diagnosis of the occult scaphoid waist fracture. Skeletal Radiol. 1998; 27(12):683-687. Observational-Dx 43 patients To compare sensitivity of MRI examination and bone scintigraphy for occult scaphoid fractures. 6 patients (14%) had scaphoid waist fractures. There were other bony injuries in a further six. In 40 patients there was agreement between the bone scintigraphy and MRI findings. In three cases there was discrepancy between the imaging modalities; in all three MRI was found to be the more sensitive and specific. 2
40. Dorsay TA, Major NM, Helms CA. Cost-effectiveness of immediate MR imaging versus traditional follow-up for revealing radiographically occult scaphoid fractures. AJR Am J Roentgenol. 2001; 177(6):1257-1263. Review/Other-Dx N/A To compare the cost of immediate screening MRI vs traditional (cast, follow-up x-ray and evaluation) for clinically-suspected scaphoid fractures with negative initial radiographs. Three of four patients with positive results at clinical examination and negative findings on initial radiographs will be needlessly immobilized and monitored. The charges to the patient at our institution for screening MRI of the wrist are $770. The total charges to the patient with the traditional protocol, which would not be necessary with screening MRI, are $677 or more if a diagnosis is not made at this time. Bone scanning or routine MRI is often eventually used. 4
41. De Zwart AD, Beeres FJ, Ring D, et al. MRI as a reference standard for suspected scaphoid fractures. Br J Radiol. 2012; 85(1016):1098-1101. Observational-Dx 124 MRI scans; 64 from healthy volunteers and 60 from the used cohort study To determine the rate of false-positive diagnosis of an acute scaphoid fracture in a cohort of healthy volunteers. To answer the primary question, only the diagnoses from the 64 scans of healthy volunteers were used. The radiologists diagnosed a total of 13 scaphoid fractures; therefore, specificity for diagnosis of scaphoid fracture was 96% (95% CI: range 94%-98%). The 5 observers had a moderate interobserver agreement regarding diagnosis of scaphoid fracture in healthy volunteers (multirater kappa=0.44; P<0.001). 2
42. Duckworth AD, Ring D, McQueen MM. Assessment of the suspected fracture of the scaphoid. J Bone Joint Surg Br. 2011; 93(6):713-719. Review/Other-Dx N/A Review imaging and management of suspected fracture of the scaphoid. The most successful diagnostic test to date is MRI, but in low-prevalence situations the PPV of MRI is only 88%, and new data have documented the potential for false positive scans. 4
43. Senall JA, Failla JM, Bouffard JA, van Holsbeeck M. Ultrasound for the early diagnosis of clinically suspected scaphoid fracture. J Hand Surg Am. 2004; 29(3):400-405. Observational-Dx 18 wrists in 18 patients To determine if US can be used to diagnose radiographically-occult scaphoid fractures. US identified correctly 7/9 cases that were eventually positive for scaphoid fracture on plain x-ray. US was read correctly as negative in 8/9 x-ray-negative cases; this was statistically significant. The 1 false-positive case had radioscaphoid arthrosis and radial wrist swelling. Sensitivity was 78% and specificity was 89%. The PPV was 88% and NPV was 80%. 2
44. Herneth AM, Siegmeth A, Bader TR, et al. Scaphoid fractures: evaluation with high-spatial-resolution US initial results. Radiology. 2001; 220(1):231-235. Observational-Dx 15 patients To evaluate the diagnostic accuracy of high-spatial-resolution US in the diagnosis of scaphoid fractures. 9/15 patients had scaphoid fractures. 7 (78%) of 9 patients had positive findings at high-spatial-resolution US and 5 (56%) had such findings at conventional radiography (ie, 4 occult scaphoid fractures), with an accuracy of 87% and 73%, respectively. Two (50%) of 4 radiographically occult scaphoid fractures were depicted with high-spatial-resolution US. US findings of scaphoid fractures were either cortical discontinuity (n=4), periosteal elevation (n=2), or a combination of these two findings (n=1). 2
45. Munk B, Bolvig L, Kroner K, Christiansen T, Borris L, Boe S. Ultrasound for diagnosis of scaphoid fractures. J Hand Surg Br. 2000; 25(4):369-371. Observational-Dx 57 patients To evaluate the diagnostic value of two different US scanning methods for the early diagnosis of acute scaphoid fractures. The accuracy of the US assessment was 84% and its specificity was 91%. However, its sensitivity was only 50%. 3
46. Breederveld RS, Tuinebreijer WE. Investigation of computed tomographic scan concurrent criterion validity in doubtful scaphoid fracture of the wrist. J Trauma. 2004; 57(4):851-854. Observational-Dx 29 patients To investigate the validity of CT scanning and bone scintigraphy compared with the clinical fracture rate during follow-up of 1-year for examining patients with a suspected scaphoid fracture. The sensitivity, specificity, and PPV and NPV of the CT scan were 100%. The sensitivity, specificity, and PPV and NPV of bone scintigraphy were 78%, 90%, 78%, and 90%, respectively. Seven patients showed a fracture on both CT scanning and bone scintigraphy. 18 patients showed no fracture on both CT scanning and bone scintigraphy. A false-positive bone scintigram showed up in two patients and a false-negative bone scintigram in another two patients. 3
47. Memarsadeghi M, Breitenseher MJ, Schaefer-Prokop C, et al. Occult scaphoid fractures: comparison of multidetector CT and MR imaging--initial experience. Radiology. 2006; 240(1):169-176. Observational-Dx 29 patients To compare the diagnostic performance of MDCT and MRI in patients clinically suspected of having a scaphoid fracture and who had normal initial radiographs, with radiographs obtained 6 weeks after trauma as the reference standard. The 6-week follow-up radiographs depicted a scaphoid fracture in 11 (38%) patients. Eight patients had a cortical fracture, while 3 patients had only a bandlike lucency within the trabecular portion of the scaphoid. MRI depicted all 11 fractures but only 3 [corrected] cortical fractures. MDCT depicted all 8 cortical fractures but failed to depict trabecular fractures. No false-positive fractures were seen on MR or CT images. Differences between MRI and CT were not significant for the detection of scaphoid fractures (P=.25) but were significant for cortical involvement (P=.03). 2
48. Ring D, Lozano-Calderon S, Shin R, Bastian P, Mudgal C, Jupiter J. A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger. J Hand Surg Am. 2008; 33(4):516-522; discussion 523-514. Experimental-Tx 84 patients To test the null hypothesis that there is no difference in resolution of triggering 3 months after injection with either a soluble (dexamethasone) or insoluble (triamcinolone) corticosteroid for idiopathic trigger finger. 6-weeks after injection, absence of triggering was documented in 22/35 patients in the triamcinolone cohort and in 12/32 patients in the dexamethasone cohort. The rates 3 months after injection were 27/41 in the triamcinolone cohort and 22/31 in the dexamethasone cohort. The triamcinolone cohort had significantly better satisfaction and Quinnell grades than did the dexamethasone cohort at the 6-week follow-up but not at the 3-month follow-up. There were no significant differences between Disabilities of the Arm, Shoulder, and Hand scores at the 6-week follow-up and the 3-month follow-up. After the close of the study, there were 8 recurrences among patients with documented absence of triggering in the triamcinolone cohort and 1 in the dexamethasone cohort. 1
49. Temple CL, Ross DC, Bennett JD, Garvin GJ, King GJ, Faber KJ. Comparison of sagittal computed tomography and plain film radiography in a scaphoid fracture model. J Hand Surg Am. 2005; 30(3):534-542. Observational-Dx 11 cadaver wrists To compare CT in the sagittal plane and plain radiography in the diagnosis of scaphoid fracture and displacement. Both x-ray and CT scans showed a high sensitivity and specificity in detecting the presence of a fracture with no interspecialty differences. The sensitivity for displacement greater than 1 mm was lower for both modalities with no inter-specialty differences. The specificities for x-ray and CT for detecting displacement >1 mm were 84% and 89%, respectively. The poor sensitivity for detecting displacement was explained by the low sensitivity of CT in the diagnosis of radial/ulnar displacement compared with x-ray and the low sensitivity of x-ray in the diagnosis of volar/dorsal displacement compared with CT scans. When fellowship-trained hand surgeons reviewed CT scans and plain radiographs together the sensitivity and specificity for fracture displacement increased significantly. Intraobserver and interobserver reliability for both x-ray and CT scans was excellent except for the reading of CT scans among emergency physicians and for the reading of plain x-rays among senior house staff, representing moderate agreement. 3
50. Bhat M, McCarthy M, Davis TR, Oni JA, Dawson S. MRI and plain radiography in the assessment of displaced fractures of the waist of the carpal scaphoid. J Bone Joint Surg Br. 2004; 86(5):705-713. Observational-Dx 50 patients To compare radiographs and MRI to determine fracture displacement in scaphoid fractures. The MRI assessments showed that only the measurement of sagittal translation of the fragments and an overall assessment of displacement had satisfactory inter- and intraobserver reproducibility and revealed that 9/50 fractures were displaced. Only 3/49 fractures with adequate follow-up failed to unite, and all were displaced with more than 1 mm of translation in the sagittal plane. If the MRI assessment of displacement of the fracture was used as the measurement of choice, assessment of displacement on the initial scaphoid series of radiographs showed a sensitivity of between 33% and 47% and a PPV of between 27% and 86%. Neither observer was able correctly to identify more than 33% to 47% of the displaced fractures from the plain radiographs. Although the overall assessment of displacement and gapping and translation in the coronal plane on the plain radiographs influenced the rate of union, none of these parameters identified all three fractures which failed to unite. 3
51. Nakamura R, Imaeda T, Horii E, Miura T, Hayakawa N. Analysis of scaphoid fracture displacement by three-dimensional computed tomography. J Hand Surg Am. 1991; 16(3):485-492. Observational-Dx 25 patients To describe analysis of a scaphoid fracture using 3D CT, and compare the 3D CT method to plain radiography. Ulnar or dorsal fracture displacement was detected in 18 patients. In the volar type, the distal fragment overhung in the volar direction relative to the proximal fragment and was frequently accompanied by humpback deformity and axial rotation. In the dorsal type, the distal fragment slipped dorsal on the proximal fragment and was commonly accompanied by humpback deformity. The volar type had a transverse or vertical fracture line on both the volar and dorsal surfaces of the scaphoid, while the dorsal type had a horizontal fracture line. The volar type was frequently found when the fracture was distal, whereas the dorsal type was noted more frequently for proximally located fracture. 3
52. Andresen R, Radmer S, Sparmann M, Bogusch G, Banzer D. Imaging of hamate bone fractures in conventional X-rays and high-resolution computed tomography. An in vitro study. Invest Radiol. 1999; 34(1):46-50. Observational-Dx 18 cadaver wrists To examine the ability to image fractures of the body and hook of the hamate bone in conventional X-rays and high-resolution CT. Taking into account all the conventional x-ray projections applied, the in vivo experiment revealed a sensitivity of 72.2%, a specificity of 88.8%, and an accuracy of 80.5%. For the high-resolution CT, the sensitivity was 100%, the specificity was 94.4%, and the accuracy was 97.2%. 3
53. Street JM. Radiographs of phalangeal fractures: importance of the internally rotated oblique projection for diagnosis. AJR Am J Roentgenol. 1993; 160(3):575-576. Review/Other-Dx 12 patients To evaluate the value of an additional oblique view in finger fractures. Internally rotated oblique increased confidence in fracture detection. 4
54. Downey EF, Jr., Curtis DJ. Patient-induced stress test of the first metacarpophalangeal joint: a radiographic assessment of collateral ligament injuries. Radiology. 1986; 158(3):679-683. Review/Other-Dx 52 patients To determine the value of patient-applied abduction/adduction stress in suspect collateral ligament injuries of the thumb metacarpophalangeal joint. 23/52 (44%) of thumbs with normal radiographs had stress examinations showing metacarpophalangeal joint subluxation compared to uninjured side representing collateral ligament injuries. 4
55. Koslowsky TC, Mader K, Gausepohl T, Heidemann J, Pennig D, Koebke J. Ultrasonographic stress test of the metacarpophalangeal joint of the thumb. Clin Orthop Relat Res. 2004; (427):115-119. Review/Other-Dx 14 cadaver wrists and 461 healthy volunteers To evaluate functional US as a tool for detecting an UCL injury of the thumb. The metacarpophalangeal joint space can be reproducibly detected on high-frequency US. An increased gap seen on US is indicative of a rupture of the UCL of the thumb. 4
56. Noszian IM, Dinkhauser LM, Orthner E, Straub GM, Csanady M. Ulnar collateral ligament: differentiation of displaced and nondisplaced tears with US. Radiology. 1995; 194(1):61-63. Review/Other-Dx 69 patients To determine the usefulness of US in the differentiation of displaced and nondisplaced tears of the UCL. Results of US corresponded to results of surgery in 37/3 patients. Findings were false-positive in six patients. 26 patients were treated conservatively with thumb casts. These patients showed stability and free range of motion at the first metacarpophalangeal joint at clinical follow-up (9-13 months). 4
57. Ahn JM, Sartoris DJ, Kang HS, et al. Gamekeeper thumb: comparison of MR arthrography with conventional arthrography and MR imaging in cadavers. Radiology. 1998; 206(3):737-744. Observational-Dx 18 cadaver thumbs To compare MR arthrography with conventional arthrography and standard MRI in the evaluation of gamekeeper thumb. 14 UCLs were torn, including 8 nondisplaced (57%) and 6 displaced (43%) tears. For the presence of tear, diagnostic accuracy of conventional arthrography, low-field-strength MRI, high-field-strength MRI, low-field-strength MR arthrography, and high-field-strength MR arthrography was 83%, 89%, 90%, 94%, and 100%, respectively. With regard to displacement of the torn ligament, diagnostic accuracy was 61%, 89%, 90%, 94%, and 100%, respectively. MR arthrograms were rated superior to standard MRIs in 72% and 90% of specimens with low-field-strength and high-field-strength magnets, respectively. 2
58. Hergan K, Mittler C, Oser W. Ulnar collateral ligament: differentiation of displaced and nondisplaced tears with US and MR imaging. Radiology. 1995; 194(1):65-71. Observational-Dx 17 patients To compare the usefulness of US and MRI in the differentiation of displaced and nondisplaced tears of the UCL. The results of US were correct in 15 patients, but displaced and nondisplaced ruptures were misinterpreted in 2 patients (sensitivity, 88%; specificity, 83% for displaced, 91% for nondisplaced). Sensitivity and specificity were both 100% for MRI. The T2-weighted sequence was more useful because the normal UCL is rarely homogeneously hypointense. 3
59. Hinke DH, Erickson SJ, Chamoy L, Timins ME. Ulnar collateral ligament of the thumb: MR findings in cadavers, volunteers, and patients with ligamentous injury (gamekeeper's thumb). AJR Am J Roentgenol. 1994; 163(6):1431-1434. Review/Other-Dx 3 volunteers, 2 cadaveric specimens, and 11 patients with acute injury To determine the MRI appearance of the UCL of the thumb in cadavers and volunteers and to analyze the MRI findings in patients with gamekeeper's thumb, especially with regard to the value of MRI in detecting clinically significant displacement of the ligament (Stener lesion). MRIs showed rupture of the UCL in all 11 patients. Prospectively, Stener lesions (n=3) could be differentiated from non-Stener lesions (n=8) in 8/11 patients. Retrospectively, the correct diagnosis could be made in all 11 patients once the importance of determining the position of the UCL relative to the adductor aponeurosis was understood. 4
60. O'Callaghan BI, Kohut G, Hoogewoud HM. Gamekeeper thumb: identification of the Stener lesion with US. Radiology. 1994; 192(2):477-480. Review/Other-Dx 48 hyperabduction injuries of the thumb To determine the value of US in recognizing the ligamentary dislocation occasionally associated with gamekeeper thumb (Stener lesion). US was positive in 13 patients, who then underwent surgery. A Stener lesion was found in 10 patients and a partial Stener lesion in three. Three patients with negative US also underwent surgery, and no dislocation was found. The other 32 patients with negative US findings were treated conservatively, and none developed subsequent instability. 4