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Opportunistic Osteoporosis Screening: Gleaning Additional Information from Diagnostic Wrist CT Scans
Joseph J. Schreiber, MD1; Elizabeth B. Gausden, MD2; Paul A. Anderson, MD3; Michelle G. Carlson, MD1; Andrew J. Weiland, MD2
1Orthopaedic Surgery, Hospital for Special Surgery, New York, NY; 2Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY; 3University of Wisconsin, Madison, WI

Introduction: Hounsfield Unit (HU) values can be easily obtained from diagnostic CT scans to calculate regional bone density. While correlations between HU and T scores, and even diagnosis of osteoporosis and osteopenia, have been established in the spine, the relationship between HU and fracture risk has yet to be investigated in the distal radius. As distal radius fractures tend to precede more devastating hip or vertebral fractures by ten to more years, these patients are an ideal target for osteoporosis screening. One means of increasing the currently low intervention rate for osteoporosis treatment could be through opportunistic diagnosis of metabolic bone disease via HU measurements from wrist CT scans. We hypothesized that HU values of the distal radius could be used to assess local bone quality and would be predictive of distal radius fracture risk, thereby allowing identification of patients in need of further management.

Methods: Bone density measurements were made in 100 patients using regional cancellous bone HU values of the distal radius, ulna and capitate (Figure 1). The HU values in 25 male and 25 female patients with an acute CT documented distal radius fracture were compared with age and gender-matched controls that had a CT scan obtained for other indications.

Results: In both male and female cohorts, age matched patients with a distal radius fracture had significantly lower regional bone density, as assessed with HU, at the distal radius, the ulnar head, and within the capitate as compared to non-fracture controls (P<0.0001, Figure 2). In females, a HU threshold of 218 in the distal radius optimized sensitivity (96%) and specificity (72%), and patients below this threshold were at increased risk of distal radius fracture (OR=3.4,P<0.001). In males, a HU value of 246 optimized sensitivity (88%) and specificity (84%) (OR=5.5,P<0.001). Control patients showed an age related decline in distal radius bone density (P<0.01), whereas fracture patients had low HU values regardless of age.

Conclusion: We found that patients with a distal radius fracture had significantly lower bone density, as assessed with HU, in the distal radius, ulna, and capitate. A distal radius HU value below 218 in females and below 246 in males was identified that is associated with a significantly increased risk for distal radius fracture. We suggest that patients with HU values below these thresholds, regardless of imaging indications, be considered for further metabolic bone disease work up, such as additional imaging, laboratory assessments, initiation of treatment, or appropriate referral.

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