a b s t r a c t

Study objective: Our aim was to determine the efficiency of Ultrasound scanning in patients with wrist trauma admitted to the emergency department and to compare US diagnostic usage with other radiological imaging methods. Methods: Patients who presented to the emergency department with wrist injury and who met the inclusion criteria and exclusion criteria were eligible. For all patients, US evaluation of the whole wrist was performed by an emergency physician before other radiological imaging methods (radiographies, computed tomography (CT) and magnetic reso- nance (MR) imaging). All of the patients included in the study underwent US, radiography, CT, and MR. Results: During the study, 122 patients were admitted with a wrist injury. After filtering for the exclusion criteria, 80 patients were included in the study. The sensitivity of US scanning in detecting fractures was 95.31% (95% confidence interval [CI]: 87.1-98.39), the specificity was 93.75% (95% CI: 71.67-98.89), and the positive predictive value was 98.39% (95% CI: 91.72-99.85), and the negative predictive value was 83.33% (95% CI: 72.98-90.41). The sensitivity of US scanning in detecting tendon and ligamentous structural injury was 66.67% (95% CI: 41.71-84.82), the specificity was 100% (95% CI: 94.42-100), the positive predictive value was 100% (95% CI: 94.29-99.89), and the negative predic- tive was 92.86% (95% CI: 84.25-97.14).

Conclusion: US scanning is an effective method that can be applied in the emergency department to adult patients to diagnose distal forearm and carpal bones fractures. In soft tissue injuries, US and MR examinations produce similar results.

(C) 2017

1. Introduction
   1. Background

The wrist and hand are the most important functional parts of the body in daily life activities and are prone to traumatic injuries [1]. These injuries constitute 6.6% to 28.6% of all injuries and 28.0% of all

? Each author certifies that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with this article. The authors declare that there are no conflicts of interest and there are no any source of funding.

?? Oguz AB, and Polat O conceived the study, and designed the trial. Oguz AB, Polat O,

and Eneyli MG supervised the conduct of the trial and data collection. Oguz AB, Gulunay B, Eksioglu M, and Gurler S undertook recruitment of participating patients and managed the data, including quality control. Oguz AB, and Polat O provided statistical advice on study design and analyzed the data. Oguz AB drafted the manuscript, and all authors con- tributed substantially to its revision. Oguz AB takes responsibility for the paper as a whole.

* Corresponding author.

E-mail address: [email protected] (A.B. Oguz).

musculoskeletal injuries [2,3]. Wrist and hand injuries account for 14.0% to 30.0% of all treated patients in emergency care [4]. Although these injuries are not life-threatening, the accepted treatment strategy for traumatic injuries is the immediate reconstruction of all injured tis- sue structures [1]. In addition to the impact of hand and wrist injuries on physical and mental health, they can lead to high health-care costs and prolonged time off from work [5]. As a consequence, these injuries may impose a considerable Economic burden on the community [5].

Importance

Fractures of the carpal bones are common after wrist trauma. Early diagnosis of these fractures is crucial to initiate appropriate therapy, which may help to prevent complications such as delayed healing, non- union, pseudarthrosis, avascular necrosis, and arthrosis of the wrist [6]. However, immediately after injury, up to 20-65% of distal forearm and carpal bones fractures, especially scaphoid fractures, remain radio- graphically occult [6,7]. Soft-tissue injuries such as tendons and

http://dx.doi.org/10.1016/j.ajem.2017.01.043

0735-6757/(C) 2017

ligaments injuries cannot be defined in radiographies or computed tomography.

Computed tomography of the wrist are used in patients with persisting complaints or equivocal findings on plain radiographs, and difficult anatomical situations. Suspected Ligamentous injuries of the wrist including tears of the triangular fibrocartilage complex are evalu- ated by wrist arthrography or magnetic resonance imaging [8]. Ultra- sound is an imaging technique that has been used for many years to examine musculoskeletal tissues [14]. At the end of the 1980s, due to its therapeutic energy ranges and its characteristic of causing pain and a tingling sensation at the site of the fracture, US evaluation was intro- duced to diagnose fractures [15]. The development of high-resolution transducers has increased the capability of ultrasound to evaluate the normal structures of the musculoskeletal system as well as to detect and characterize subtle pathological changes [9]. US allows the detec- tion of foreign bodies and the reliable identification of a variety of trau- matic lesions affecting tendons, annular pulleys, ligaments, vessels and nerves [10]. Ultrasound is an efficient, rapid and inexpensive imaging technique for wrist evaluation [9,10]. Compared with MR, US has sever- al advantages including comparative and dynamic imaging capabilities, higher spatial resolution, wider availability, and lower cost in detecting wrist tendons [16]. For successful US evaluation in terms of experience and the integrity of the whole examination, time will be needed. For Prompt diagnosis, focused US on symptomatic parts of the body is pref- erable; to avoid leaving the possibility of another diagnosis open, rou- tine wide-scope US examinations are preferred approaches [17]. Previous studies showed that many pathological examinations could be diagnosed with focused evaluation [18]. In addition to a comprehen- sive examination, focused US is increasing the rate of reported diagnoses.

Few studies showed that US sensitivity is 89.06-100% and specificity

is 94.29-98% in diagnosing fractures in wrist region [22-23]. We can find one study reported in the literature about US sensitivity and speci- ficity in diagnosing tendon and ligamentous injuries in wrist region. This study demonstrated that US sensitivity and specificity in diagnos- ing tendon and ligamentous injuries are 100% in this region [25].

Goals of this investigation

Our aim was to determine the efficiency of US scanning in patients with wrist trauma admitted to the emergency department and to compare US diagnostic usage with other radiological imaging methods (radiographies, CT, and MR imaging).

1. Methods
   1. Study design

This was a cross-sectional, prospective study conducted from Janu- ary 2014 to October 2014 in an academic emergency department. Writ- ten informed assent and consent was obtained from all participants. Approval for this study was granted by the local university institutional review board.

Setting

The physician applying US (primary physician) attended many mus- culoskeletal US workshops and congresses. Currently, training in US is part of the curriculum of our emergency medicine residency program.

Ultrasound, applied to all patients in emergency department, was performed in accordance with the European Society of Musculoskeletal Radiology, Wrist Ultrasound Technical Guidelines [11]. Ultrasonograph- ic examinations were performed before other radiological imaging methods (radiography, CT, and MR). Ordering other radiological exam- inations and treatments of the patients were overseen by another physician. The clinician who performed the US did not see the other

radiological imaging methods and their interpretations. Patients with wrist injuries had their wrist anteroposterior and lateral X-rays and ulnar deviation X-ray taken. CT analysis of the wrist joint was also per- formed in emergency department. Despite it is not a routine emergency department practice pattern, for evaluate soft tissue injury MR analysis of the wrist joint was performed all patients within five days after emer- gency department admissions. In this way, all of the subjects included in the study underwent ultrasonography, radiography, CT, and MR. At the end of the study, all of the radiological images were interpreted by an Orthopedic specialist. The research study protocol did not disrupt the clinical management of the patients.

Selection of participants

During the study, the triage nurse made contact with the primary physician in charge of the study when a patient with wrist injury pre- sented. In this way, the physician in charge of selecting the patients en- sured that they met the inclusion criteria and exclusion criteria. Aged 16 or older, provided written consent, conscious and stable patients were included the study. Unstable, exposed to penetrating trauma, with Open fractures and apparent dislocation, with chronic problems such as osteomyelitis, having contraindications for magnetic resonance im- aging and pregnant patients were excluded the study.

Methods of measurement

The primary physician recorded the patients’ sex, age, the cause of the injury (simple fall, sport injury, motor vehicle accident, assault, fall from height), and whether the injury was to the left or right wrist. Phys- ical examination findings were recorded, and fractures of the bone structures and soft tissue (tendons and ligaments) injuries were imme- diately evaluated by the primary physician in charge. All data were imported into SPSS 15 for Windows (SPSS Inc., Chicago, IL).

The ultrasonographic images were obtained by a LOGIQ Book XP (General Electric, Logiq book XP, Turkey) device and Linear probe (10 MHZ). The CT scan was performed using a Toshiba Asteion S4 (Toshiba Asteion 4, Toshiba Medical System, Japan) with four detectors. No oral or intravenous contrast matters were used. The MR scan was performed using a General Electric 450 W Optima (General Electric Company, USA) having 1.5 T 16 channels. No oral or intravenous contrast matters were used.

Analysis

Sample size was calculated based on a previous study in which there was a 13% difference in the identification of fracture between US and other radiological imaging methods [6]. By using this value to obtain the sample size, we determined that 70 patients was minimum sample size to yield a type I error of 0.05 and power of 90%.

Statistical analysis was performed with SPSS 15 for Windows (SPSS Inc., Chicago, IL). Descriptive statistics are shown as average + standard deviation for variables with a normal distribution, as median (min – max) for variables with an abnormal distribution and as the number of cases and (%) for nominal variables. Nominal var- iables were evaluated with Pearson Ki-Kare. In researching the harmony between classified values obtained by each method, the kappa correla- tion coefficient relevance was calculated. In researching method com- pliances, the sensitivity, specificity, false positive, false negative, positive likelihood ratio, negative likelihood ratio and 95% confidence intervals for each calculated. Results of p b 0.05 are accepted as statisti- cally significant. In the study of bone structures, sensitivity and specific- ity values for US were calculated. CT is taken as the gold standard. In researching soft tissue, the sensitivity and specificity values for US were calculated. MR was taken as the gold standard.

Table 1

Demographics and clinical characteristics (N = 100).

SubjeCT characteristics Percentage (%)^a

Median age, years 43.5 (16-82)

Male, % 70

Context of injury, %

Falling 60

Sports activities 26.3

Motor vehicle accident 10

Other 3.7

Bone fractures, %

Distal radius 40.6

Both distal radius and distal ulna 32.8

Scaphoid 12.5

Triquetrum 4.7

Other 9.4

Tendon and ligament injuries, %

Extensor pollicis longus tendon 26.7

Scapholunate ligament 20

Flexor retinaculum 13.3

Extensor carpi radialis longus tendon 13.3

Abductor pollicis longus tendon 13.3

Other 13.3

^a Data are presented as percentage unless otherwise indicated.

1. Results
   1. Characteristics of study subjects

During the study, 122 patients were admitted with wrist injury due to fall, fall from height, sports injuries, assault, or motor vehicle accident. Of those, 26 were younger than 16. Seven of the patients were unstable, two had open fractures, three were taken into surgical intervention right away, three did not want to participate in the study, and one was excluded because of an MR imaging contraindication (heart pace- maker). As a result, 80 patients with wrist injury were included in the study. Their clinical information is presented in Table 1.

The mean age of all patients was 46.36 +- 18.43 (16-82) years. Fifty- six patients (70%) were male, and 24 (30%) were female. Forty-nine pa- tients had injured their right wrists (61.3%), while 31 injured their left wrists (38.3%). In 48 patients (60%), the activity causing the injury

was determined to be falling. Twenty-one patients (26,3%) were injured during sports activities, and eight patients (10%) were injured by motor vehicle accident. Two patients (2,5%) were injured because of assault, and one patient (1,3%) was injured because of fall from height.

During the study, bone fractures were found in 64 patients. Twenty- six (40,62%) were Distal radius fractures, and 21 (32,81%) were both dis- tal radius and distal ulna fractures. Eight (12,5%) were scaphoid frac- tures, three (4,68%) were triquetral fractures, and two (3,13%) were pisiform fractures. There was only one instance each of a trapezium fracture (1,56%), a hamate fracture (1,56%), a capitate fracture (1,56%), and a trapezoid fracture (1,56%).

Tendon and ligament injuries were found in 15 patients. Of all ten- don and ligament injuries, four (26.66%) were an extensor pollicis longus tendon injury, three (20%) were a scapholunate ligament injury, two (13.33%) were a flexor retinaculum injury, two (13.33%) were an extensor carpi radialis longus tendon injury, and two (13.33%) were an abductor pollicis longus tendon injury. Only one (6.66%) was a flexor carpi radialis tendon injury, and one (6.66%) was an extensor carpi radialis brevis tendon injury.

Main results

Radiographies were determined only 59 (92,19%) bone fractures of the total 64 bone fractures. In CT examinations of these patients, two of them were determined as not having any bone fractures. Radiogra- phy examination of these two patients were evaluated as scaphoid frac- tures. In the total 80 patients, radiography examination identified 14 suspicious bone fractures. No bone fractures were found in the CT exam- inations of these patients. Radiography failed to identify two distal radi- us fractures, one hamate fracture, one trapezium fracture, one capitate fracture, one trapezoid fracture, and one pisiform fracture. Using MR ex- aminations, fractures were found in 64 patients. All of the fractures de- termined in the CT analysis (which we accept as the gold standard for bone tissue examination) were also identified by MR examinations.

Fractures were determined with US in 62 patients. In one patient di- agnosed with scaphoid fracture by US examination, the CT examination revealed that there was no fracture. One distal radius fracture, one capitate fracture and one trapezoid fracture were not identified by US examinations. One distal radius fracture, one hamate fracture, one

Fig. 1. Fractures lines on US images; a: pisiform, b: scaphoid, c: triquetrum.

Table 2

sensitivity and specificity rates of US for diagnosing bone fractures.

			CT		Total
			Without fractures	With fractures
US Without fractures n			15	3	18
%			93,8%	4,7%	22,5%
	With fractures	n	1	61	62
		%	6,2%	95,3%	77,5%
Total		n	16	64	80
		%	100%	100%	100%

trapezium fracture, and one pisiform fracture that were not identified by radiography were determined by US. The US images from some pa- tients with fractures are shown in Fig. 1. When CT examination was taken as the gold standard, the sensitivity of US scanning in detecting fractures was 95.31% (95% CI: 87.1-98.39), the specificity was 93.75%

(95% CI: 71.67-98.89), the positive predictive value was 98.39% (95%

CI: 91.72-99.85), and the negative predictive value was 83.33% (95% CI: 72.98-90.41) (Table 2). The total accuracy ratio was 95%, and the Kappa value was 0.85. The ratio of detection of the fractures of US was found to be statistically significant (p b 0.05).

A total of 14 suspicious scaphoid fractures were detected during our study. When CT examination was taken as the standard, the sensitivity of US scanning in detecting scaphoid fractures was 100% (95% CI: 67.56- 100), the specificity was 83.33% (95% CI: 43.65-96.99), the positive pre- dictive value was 88.89% (95% CI: 59.62-98.60), and the negative pre- dictive value was 100% (95% CI: 73.24-99.34). The total accuracy ratio was 92.86%, and the Kappa value was 0.85. The ratio of detection scaph- oid fractures by US was statistically significant (p b 0.05).

US examinations identified 10 (66.67%) tendon and ligament inju- ries of the total 15 tendon and ligament injuries. In five patients, tendon and ligament injury was not identified by US. Of these, two were partial ruptures in the extensor pollicis longus tendon, whereas two had partial ruptures in the flexor retinaculum, and one had a partial rupture in the flexor carpi radialis tendon. US images of some patients with tendon and ligament injuries are shown in Fig. 2. When MR examination was taken as the gold standard, the sensitivity of US scanning in detecting tendon and ligamentous structure injury was 66.67% (95% CI: 41.71- 84.82), the specificity was 100% (95% CI: 94.42-100), the positive pre- dictive value was 100% (95% CI: 94.29-99.89), and the negative predic- tive value was 92.86% (95% CI: 84.25-97.14) (Table 3). The total accuracy ratio was 93.75%, and the Kappa value was 0.76. The ratio of detection of the tendon and ligament injuries of US was statistically sig- nificant (p b 0.05).

1. Limitations

In the present study, the US examination was performed by one phy- sician. As a result, not all patients admitted to the emergency depart- ment with wrist injuries could be included in the study. This is the major limitation of our study. However, the day and night randomiza- tion was taken into consideration. Only patients over 16 years old were included into the study, so we cannot make any comments on the usage of US in pediatric wrist injuries. Only one patient with a cap- itate fracture and one patient with a trapezoid fracture were admitted to the study, so we think that the study results of these two bones are not sufficient to draw conclusions regarding the abilities of the different im- aging methods to identify these injuries.

We did not record the data of average waiting time spent on US, CT, and MRI. Also we did not make the compression of the average cost of US with average cost of CT and MRI. These are other limitations of our study.

1. Discussion

In the present study, bone, tendon, and ligamentous structures in the wrist were examined with a comprehensive US evaluation. In addition, a more detailed examination was performed in areas with intense symptoms. We found ultrasonography sensitivity in detecting fractures of 95.31% (95% CI: 87.1-98.39), and specificity of 93.75% (95% CI: 71.67-

98.89). We report an ultrasonography sensitivity in detecting tendon and ligamentous injuries of 66.67% (95% CI: 41.71-84.82) and specificity of 100% (95% CI: 94.42-100). Although there are few studies on the ef- fectiveness of US in detecting wrist-area injuries, our study results are similar with previous studies’ results [22,23,25]

Leslie and Dickson reported that 98% of carpal bone fractures were visible on radiography at the first examination, while 2% of them be- came visible after two weeks on radiography [19]. Other authors have reported less optimistic figures as low as 84% visible on first examina- tion [20,21]. In our study, 89% of carpal bones fractures were identified by radiographies.

As similar our results, Javadzadeh et al. reported that US sensitivity was 89.06% and specificity was 94.29% in diagnosing fractures in wrist region [22]. During our study, 14 suspicious scaphoid fractures were de- tected. In detecting scaphoid fractures, the sensitivity of US was 100% (95% CI: 67.56-100), and specificity was 83.33% (95% CI: 43.65- 96.99). Hauger et al. reported that US sensitivity was 100%, and specific- ity was 98% [23].

By comparing the results of US and MR examinations of Soft tissues such as tendons and ligaments, we have shown that except for very

Fig. 2. US images; a: extensor pollicis longus (EPL) tendon rupture; absent EPL tendon next to Lister’s tubercule (*), b: rupture in scapholunate ligament.

Table 3

Sensitivity and specificity rates of US for diagnosing tendon and ligament injuries.

Magnetic resonance imaging Total

			Without pathology	With pathology
US Without pathology n			65	5	70
%			100%	33,3%	87,5%
	With pathology	n	0	10	10
		%	0%	66,7%	12,5%
Total		n	65	15	80
		%	100%	100%	100%

small partial ruptures, soft-tissue injuries caused by trauma can deter- mined by US examination. Lesions that cannot be evaluated by US ex- aminations but were seen in MR imaging did not have an effect on the patients’ Healing process. Rasmussen stated that complete tendon tears rarely present imaging problems, but partial tears are much more challenging to diagnose [24]. Finlay et al. demonstrated that US sensitivity and specificity in diagnosing tendon and ligamentous inju- ries were 100% in patients 17 years or older in this region [25].

Finlay et al. stated that US can be a valuable tool, most reliably in the detection of wrist-area tendon tears [25]. Chiou et al. suggested that ul- trasonography of the wrist should be a routine examination for wrist pain [26]. Jenkins et al. stated that ultrasound is cheaper than the other radiological imaging methods [27]. According to our study, US scanning is an effective method for identifying the skeletal trauma and for soft tissue trauma of patients with injured wrists.

1. Conclusions

In the present study, we investigated the accuracy of US scanning in patients with wrist trauma admitted to the emergency department and compared US diagnostic usage with other radiologic imaging methods. We determined that US scanning is an effective method that can be ap- plied in the emergency department in adult age groups to diagnose dis- tal forearm and carpal bones fractures. We also determined that in soft tissue injuries US examinations results are similar to those of MR.

In summary, our study showed that US scanning is a valuable tool in the emergency department for patients with wrist trauma because it is an easy, irradiation-free, fast, and inexpensive imaging method that permits the simultaneous evaluation of both bones and soft tissues. Be- cause US examination is performed by the same physician who exam- ines the patient, its effect on the probability of accurate diagnoses and decisions is of great importance in emergency services triage.

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