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Diagnosis of Occult Scaphoid Fractures Using Digital Tomosynthesis Versus MRI
Timothy Paul Dooley, MD1; Joe Messana, MD1; David Quinn, MD2
1Alany Medical Center Hospital, Albany, NY, 2Capital Region Orthopaedics, Albany, NY
Introduction: Minimally displaced and non-displaced scaphoid fractures are often not detected on early radiographs. Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) have improved diagnostic accuracy but are expensive. Digital tomosynthesis is a new imaging modality that uses a series of radiographs taken from different angles and combines them into a digital single-plane tomographic image. The purpose of this study was to evaluate the effectiveness of digital tomosynthesis in identifying occult scaphoid fractures not detected on plain radiographs. Secondary outcome measures were the amount of radiation exposure of the digital tomosynthesis, the wait time for an MRI, and the cost of the tomosynthesis compared to an MRI.
Methods: After IRB approval, twenty-eight patients with a physical examination concerning for scaphoid fracture but with negative initial radiographs had digital tomosynthesis performed in the office. If the tomogram showed a fracture of the scaphoid, no further testing was ordered. In those patients that did not have a fracture identified on tomogram, an MRI was ordered. The results of the negative tomosynthesis and the subsequent MRI findings were compared to determine the sensitivity of the digital tomosynthesis.
Results: Ten of twenty-eight patients with initial negative plain radiographs had a fracture of the visible on the digital tomogram. Six of these patients were treated in a cast and four underwent open reduction internal fixation. Two patients had questionable findings on the tomogram and underwent MRI examination that failed to demonstrate a scaphoid fracture. The remaining sixteen patients had negative tomographic studies. Of these, twelve underwent an MRI, and four declined an MRI. Of the twelve MRI studies, all were negative for scaphoid fracture, but two showed capsular avulsion injuries and two showed ligamentous injuries. Two patients elected to not get an MRI after their negative tomogram and they clinically improved, and two patients did not follow up with the practice after their negative tomogram.
Secondary study outcomes showed the average dose of radiation for a tomosynthesis of the wrist in two views was 2.1mGY. Patients waited an average of 12.2 days before obtaining their MRI exams. The charge for the tomosynthesis examination was $278 compared to $1573 for an MRI of the wrist.
Conclusion: Digital tomosynthesis is another tool that has the ability to help the clinician diagnose fractures in the office prior to an MRI. It results in a timely secondary evaluation following a negative initial radiograph, with a strong negative predictive value.
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