Emerg Radiol DOI 10.1007/s10140-017-1559-6
ORIGINAL ARTICLE
Does radiography still have a significant diagnostic role in evaluation of acute traumatic wrist injuries? A prospective comparative study Mohammad Abd Alkhalik Basha 1 Ahmed Hatem F. Imam 2
&
Ahmad Abdel Azim Ismail 1 &
Received: 12 July 2017 / Accepted: 18 September 2017 # American Society of Emergency Radiology 2017
Key points -Acute traumatic wrist injuries are more common and result in a considerable functional effect on daily activities. So, it is essential to rapidly manage. -Radiography still remains the first screening tool in acute traumatic wrist injuries due to its wide availability, low radiation dose, and low costs in comparison to MDCT. -MDCT is complementary to digital radiography. -In cases where there is a doubt or equivocal primary radiographic findings as in complex distal radius fractures and clinically suspected scaphoid bone fractures, the MDCT can be used to confirm or exclude the presence of fractures and put a preoperative road map if the surgery is decided.
trauma. The diagnostic role of radiography and MDCT was evaluated and compared. The effective radiation dose of the two techniques was calculated. Results One hundred four (61.9%) and 84 (50%) out of 168 patients had acute wrist injuries on MDCT and radiographic examinations, respectively. Using MDCT results as a reference standard, the sensitivity, specificity, and accuracy of radiography in the diagnosis of distal radius fracture were 85.7, 96, and 92.3%, respectively, and in the diagnosis of scaphoid fracture were 62.5, 97.3, and 88.5%, respectively. As regards detection of acute traumatic wrist injuries, we observed no significant difference between the two modalities (P = 0.1347); in addition, both modalities had high consistency (κ = 0.8359). The mean effective radiation dose of radiography was 0.01 mSv and of MDCT was 0.1 mSv. Conclusion Radiography still remains as the first screening tool in acute traumatic wrist injuries and MDCT is complementary to it and used as a problem-solving tool or for preoperative planning.
Methodology • Prospective • Diagnostic or prognostic study • Performed at one institution
Keywords Radiography . MDCT . Acute traumatic wrist injuries
Abstract Aim The aim of this study was to evaluate and compare the diagnostic role of radiography and multi-detector computed tomography (MDCT) in acute traumatic wrist injuries. Patients and methods One hundred sixty-eight patients with acute wrist trauma were enrolled in our study. All patients had submitted to radiography and MDCT within 24 h after wrist
* Mohammad Abd Alkhalik Basha
[email protected] Ahmad Abdel Azim Ismail
[email protected] Ahmed Hatem F. Imam
[email protected] 1
Department of Diagnostic Radiology, Zagazig University, Zagazig, Egypt
2
Department of Orthopaedic Surgery, Zagazig University, Zagazig, Egypt
Introduction The wrist joint is one of the extremely complex joints in the human body. However, its anatomy can be simply divided into three major partitions: the distal radioulnar joint, the radiocarpal joint, and the mid-carpal joint [1]. It is one of the joints that is frequently subjected to injury and results in a considerable functional effect on daily activities. So, it is essential to rapidly and well manage injuries of the wrist [2].
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The assessment of patients with suspected wrist injuries is a diagnostic challenge. In several cases, the clinical examination does not yield a confident diagnosis and radiographic examination routinely done in the initial assessment of a suspected wrist fracture may be negative, due to overlapping structures, suboptimal technique and positioning, lack of special radiographic views, and other problems related to radiographic analysis. So, missed fracture or injury of ligaments may cause insufficient management and serious complications [3, 4]. Recently, the advancement of multi-detector computed tomography (MDCT) and its multiplanar reformation ability with thin sections produces a high spatial resolution to detect radiographically occult wrist fractures [5]. The aim of this study was to evaluate and compare the diagnostic role of radiography and MDCT in patients with acute traumatic wrist injuries.
Material and methods Patients The current prospective study included 168 consecutive patients who came to the emergency department of our institution complained of wrist pain within 24 h after wrist trauma during the period from January 2016 till May 2017. Approval for this study was obtained from the Institutional Review Board, and all included patients gave informed consents. Inclusion criteria Adult patients presented within 24 h after wrist trauma. Exclusion criteria Cognitive disorders and previous trauma. All patients were submitted to radiography in three views (lateral, posteroanterior, and semipronated oblique) followed by MDCT examination with sagittal and coronal reconstructions. Radiography examination Radiography was performed using a commercially available flat detector direct digital system in the emergency room. Posteroanterior, lateral, and semipronated oblique views were made in each patient. If the scaphoid fracture was suspected, additional view (posteroanterior with ulnar deviation view) was done. The central beam was focused on proximal carpal bones. The parameters of imaging were established as follows: tube current 1.9 mAs, film-focus distance 115 cm, and voltage 50 kV. Imaging was done with the patient seated on a chair, putting his hand on the Bucky table in three to four different positions.
MDCT examination All patients had submitted to a wrist CT on a 128-multidetector scanner (Brilliance; Philips Medical Systems). The routine wrist MDCT protocol was achieved as follows: matrix 512, beam pitch 0.688, interval 0.75 mm, collimation 16 × 0.75 mm, 120 kV, 120 mA, gantry rotation time 0.75 s, and total exposure time 15–20 s. Routine multiplanar reformats with coronal and sagittal planes were done as follows: slice thickness 1.0 mm and reconstruction increment 0.75 mm. Three-dimensional (3D) reconstructions were performed when requested by the orthopedic surgeon. Dose calculation The radiation dose is usually defined as effective dose (E). The scientific unit of measurement of E is the millisievert (mSv). In imaging examinations of the wrist, only skin and bones contribute to the E; other organs were unrelated due to their distance from the cone-beam. In radiography, we recorded the dose field product (dGy × cm2). The E of radiography was estimated by calculating the energy imparted (€). The € was obtained from the dose area product incident on the patient. The € value was then consequently converted into corresponding E using an extremity-specific E/€ ratio. In MDCT, CT dose index volume (CTDI vol), the effective tube current, and dose-length product (DLP) were obtained from the patient protocol of the system. The E was obtained from the result of DLP and conversion coefficient for the examined wrist. The E of each technique was calculated to compare the radiation load in each patient. Image analysis and interpretation The radiography and MDCT were done on the same day. Image data from radiography and MDCT were separated for interpretation (i.e., image features at radiography were interpreted without knowledge of the MDCT images or results and vice versa). Two radiologists who had experience in musculoskeletal radiology (A.A.I., and M.A.B., with 17 and 12 years of experience, respectively) independently reviewed the data sets and for each injury recorded the type, side, site, number, and degree of displacement. Acquisition date and participant identification were removed from all images. The radiologists were blinded to all clinical information. The independent review was strictly ordered by radiography first and MDCT data second, and the interval between reading sessions was 4 weeks to avoid the interaction potential between the two data sets. In order to determine the consistency between the radiography and MDCT imaging for detecting wrist injury, the results for each injury scaled by two independent readers in each group were integrated into a final score. During this procedure, any interreader disagreement in classifying
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radiography and MDCT features of the injury was discussed until consensus was reached. For example, if an injury was assigned to a simple fracture by both two readers, the final result was a simple fracture. On the other hand, if one reader reported the injury as a simple fracture while another as a compound fracture, a result with reader consensus was considered. All image analysis was done by using images displayed on computer monitors with picture archiving and communication system. Reference standard
Table 1 Demographic and clinical data of the injured patients detected by MDCT Variable Mean ± SD Range
No.
%
Sex
Female Male
36 68
34.6 65.4
Side of lesion
Left Right
60 44
57.7 42.3
Trauma type
Indirect
12
11.5
Direct Direct open wound
92 28
88.5 30.4
We considered MDCT findings as the reference standard and compared radiography findings with it. Statistical analysis Results were collected, analyzed, tabulated, and summarized statistically using SPSS for data processing and statistics. We used Cohen’s kappa (κ) test and 95% CIs to determine the intra-class agreement (ICA) of imaging results between radiography and MDCT data for the diagnosis of wrist injuries. The κ values were interpreted as follows: slight agreement, 0.01–0.20; fair agreement, 0.21–0.40; moderate agreement, 0.41–0.60; substantial agreement, 0.61–0.80; and almost perfect agreement, 0.81–0.99. We used a fourfold table to evaluate the diagnostic performance of radiography for assessment of acute wrist injuries using MDCT as a reference standard. P value ≤ 0.05 was respected statistically significant.
(n = 104)
Age (years
Number of lesions
38.81 ± 7.31 16–63
Direct closed wound
64
69.6
Single lesions
88
84.6
Two lesion Three lesions
12 4
11.5 3.9
Results Study population We conducted this study on 168 patients with acute wrist trauma. The age of the studied group ranged from 16 to 63 years with mean 38.81 ± 9.25 years. Regarding sex distribution, 64 patients were female (38.1%) and 104 patients were male (61.9%). We detailed the demographic and clinical data of injured patients detected by MDCT in Table 1. The majority of our patients were young age, so interpretation of images was not difficult; however, we had seven old aged patients with significant osteopenia and degenerative changes which limited to some extent the interpretation of images (Fig. 1). MDCT findings One hundred four of 168 (61.9%) patients had wrist injuries on MDCT examination; of these 104 patients, 88 had one injury, 12 had two injuries, and 4 had three injuries, so the
Fig. 1 A 23-year-old male came to the emergency room (ER) complained of left wrist pain after falling on an outstretched hand. a Posteroanterior and b lateral radiographic images with no detectable fracture. c Coronal and d sagittal reformatted CT images reveal oblique fissural fracture line in the middle third of the scaphoid (yellow arrows)
Emerg Radiol Fig. 2 A 30-year-old male came to ER complained of right wrist pain after motor vehicle accident. a Posteroanterior and b lateral radiographic views of the right wrist revealed non-displaced intra-articular distal radius fracture (yellow arrows). c Coronal and d sagittal reformatted CT images show non-displaced intra-articular distal radius fracture (yellow arrow). e Axial CT image reveals fracture distal radius (yellow arrow). f, g 3D reformatted CT image display non-displaced intra-articular distal radius fracture (yellow arrow)
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sum of injuries detected by MDCT were 124 [104 (83.9%) bone fractures and 20 (16.1%) bone dislocation] (Table 1). 53.8% of the fractures were in distal radius (Figs. 2, 4, 5,
and 6), 30.8% were in the scaphoid bone (Figs. 1 and 3), and 15.4% were in the ulnar styloid process (Fig. 4). 65.4% of fractures were displaced and 34.6% were un-displaced (Table 2).
Fig. 3 A 35-year-old male came to ER with left wrist pain after a car accident. a Lateral, oblique, and posteroanterior radiographic views respectively from right to left reveal perilunate dislocation (yellow arrow) with no scaphoid fracture is detected. b Coronal reformatted CT image displays scaphoid waist fracture (green arrow). c Axial CT image shows scaphoid pieces (green arrows). d Sagittal reformatted CT image demonstrates trans-scaphoid perilunate dislocation. e 3D reformatted CT image illustrates trans-scaphoid perilunate fracture dislocation (yellow arrow)
Fig. 4 A 25-year-old female came to ER complaining right wrist pain after a car accident. a Oblique radiographic view shows intra-articular distal radius fracture. b Coronal reformatted CT image shows nondisplaced vertical intra-articular distal radius and shaft fractures (yellow arrows). c Axial CT image demonstrates distal radius fracture (yellow arrow). d Sagittal reformatted CT image displays non-displaced intraarticular distal radius fracture (yellow arrow). e 3D reformatted CT image displays intra-articular distal radius and shaft fractures (red arrows), and also shows ulnar styloid process fracture (green arrow)
Emerg Radiol Table 2 Comparison of type, site, and displacement degree of injuries detected by radiography and MDCT among the studied patients
Variable
Type of injuries Site of fracture
Radiography (n = 100)
MDCT (n = 124)
No.
%
No.
%
Fracture
84
67.7
104
83.9
Dislocation
16
12.9
20
16.1
Distal radius
48
57.1
56
53.8
Intra-articular Extra-articular
40 8
83.3 16.7
48 8
85.7 14.3
Scaphoid Waist
20 16
23.8 80
32 26
30.8 81.25
Proximal pole
Displacement
0
0
2
Distal pole Ulnar styloid process
4 16
20 19.1
4 16
12.5 15.4
6.25
Other carpal bones Displaced
0 67
0 79.8
0 68
0 65.4
Un-displaced
17
20.2
36
34.6
MDCT multi-detector computed tomography, n number
Radiographic findings Eighty-four of 168 (50%) patients had wrist injuries on radiographic examination; of these 84 patients, 72 had one injury, 8 had two injuries, and 4 had three injuries (Table 1), so the sum of injuries detected by radiography were 100 (84 bone fractures and 16 bone dislocations). 57.1% of the fractures were in the distal radius, 23.8% were in the scaphoid bone, and 19.1% were in the ulnar styloid. 79.8% of fractures were displaced and 20.2% were un-displaced (Table 2). Twenty-four of 124 (19.4%) injuries diagnosed by MDCT could not be detected by radiography [4 (16.7%) dislocations, 8 (33.3%) distal radius fracture, and 12 (50%) scaphoid fracture]. Intra-class agreement (ICA) for wrist injuries using radiography and MDCT The inter-observer reliability between two readers in detecting overall wrist fracture was almost perfect on both radiography (κ = 0.901) and MDCT (κ = 1.000). ICA was almost perfect between radiography and MDCT for the detection of ulnar fracture (κ = 1.0), distal radius fracture (κ = 0.9438), wrist dislocation (κ = 0.9352), overall wrist fracture (κ = 0.8790), and scaphoid fracture (κ = 0.8280) (Table 3). Radiography produced false negative findings of distal radius fracture in 14.3% (8 of 56), a scaphoid fracture in 37.5% (12 of 32), and overall wrist fracture in 19.3% (24 of 124) compared to MDCT (Table 3). Diagnostic performance of radiography Table 4 demonstrates the diagnostic performance of radiography in the diagnosis of wrist injuries using MDCT as a reference standard. Radiography produced significantly higher
accuracy and sensitivity for detection of distal radius fracture (P < 0.005) but had lower sensitivity and higher specificity for detection of scaphoid fracture (P < 0.01) (Fig. 5). The radiation doses from MDCT and radiography The average effective dose of MDCT was 0.1 mSv and of radiography was 0.01 mSv.
Discussion Wrist fractures are widespread injuries of the skeletal system and might be diagnostic challenges in emergency rooms [6]. Radiographic examination is routinely used in the initial assessment of a suspected acute wrist fracture but might be negative [7]. CT is a commonly utilized imaging modality following radiography. Due to technical advances, MDCT is faster and has better temporal, spatial, and contrast resolution Table 3 The intra-class agreement (ICA) of wrist injuries determined by using radiography or MDCT Variable
Wrist fracture Wrist dislocation Radius fracture Scaphoid fracture Ulnar fracture
Intra-class correlation coefficients Kappa (κ)
95% CI
0.8790 0.9352 0.9438 0.8280 1.000
0.7749 to 0.9350 0.8795 to 0.9652 0.8955 to 0.9698 0.6801 to 0.9076 1.000 to 1.000
P value
0.2634 0.2634 0.2634 0.2634 0.2634
MDCT multi-detector computed tomography, CI confidence interval
Emerg Radiol Table 4 Diagnostic performance of radiography in diagnosis of wrist injuries in comparison to MDCT as reference standard
Diagnostic performance
Wrist fracture
Wrist dislocation
Radius fracture
Scaphoid fracture
Ulnar fracture
Accuracy Sensitivity
77.4% 76.9%
96.8% 80%
92.3% 85.7%
88.5% 62.5%
100% 100%
Specificity PPV
80% 95.2%
100% 100%
96% 96%
97.3% 9.9%
100% 100%
NPV
40%
96.3%
85.7%
85.7%
100%
P value
0.02
< 0.001
0.005
0.01
< 0.001
PPV positive predictive value, NPV negative predictive value
than digital single-slice CT. Furthermore, MDCT with multiplanar reformation is valuable in detecting fracture patterns, especially in complex joint fractures, where they show occult fractures and illustrate the accurate number of fracture components and their degree of displacement [8, 9] (Fig. 6). The current study was done to assess and compare the diagnostic role of radiography and MDCT in acute traumatic wrist injuries. In this study, we investigated 168 patients who underwent radiography and MDCT examinations within 24 h of wrist trauma. One hundred four (61.9%) and 84 (50%) of 168 patients had wrist injuries on MDCT and radiographic examinations, respectively. As reported by previous authors [10, 11], we found that males had a higher prevalence of wrist fractures (65.4% were male and 34.6% were female), but some studies have also reported an equal male to female ratio as regards wrist fracture [12]. We found left-sided fracture predominance in the wrist (57.7%). This result is similar to result of Balci et al. [13], which revealed that left-sided fracture prevalence (53.7%) was significantly higher than right-sided fracture prevalence (44.4%), but in contrast to Dennis et al. [10], which registered 90% of patients having right-sided fracture predominance in their study and Van et al. [12] which demonstrated an equal involvement of the right and left hand. In our study, the most common fracture type was the distal radius (54%). This result is in agreement with the result of Kiuru et al. [4] and with MRI study done by Pierre et al. [14] which recorded that, the distal radius is the most common site of occult fracture in patients with wrist trauma who had negative or equivocal radiographic findings. CT is the most accurate examination for detecting the distal radial fracture extension and exactly quantifies the degree of articular surface involvement and its incongruity. CT reliably differentiates between patients for whom surgery is designated, preventing accelerated osteoarthritis in this group, from patients in whom only a conservative treatment is needed [15]. Our study revealed that radiography is usually sufficient to diagnose distal forearm fractures where the sensitivities of radiography for distal radius and ulnar fractures were 85.7
and 100%, respectively. Eight of 56 patients with distal radius fracture were missed at radiography. All these eight patients had non-displaced distal radius fracture with intra-articular extension and the radiography failed to detect this extension. These results are concordant with results of Balci et al. [13], in which the sensitivity of radiography for distal radius fractures was 72.8% and for ulnar fractures was 90%. Also, the study of Pierre et al. [14] supported our results as regards distal radius fractures. The second most common fracture type in this study was scaphoid fracture which made up about 31% of all wrist injuries. A scaphoid fracture may be occult and if missed might result in complications such as nonunion, osteonecrosis, and posttraumatic arthritis, so the detection of a scaphoid fracture is essential [16]. In our study, 32 patients were diagnosed by MDCT as having a scaphoid fracture. Twenty of 32 patients were correctly diagnosed by radiography and 12 were missed after making all radiographic views. The sensitivity and accuracy of radiography for scaphoid fracture detection were 62.5% and 88.5%, respectively, so the radiography was significantly inferior to MDCT (p = 0.01) as regards scaphoid fracture detection. These results emphasized the limited diagnostic value of radiography in acute scaphoid fractures. So, early diagnosis and treatment planning cannot be confident if diagnosis depends on radiography only. This is compatible with the previous studies [13–22] that revealed the limited value of radiography in scaphoid fracture detection and supporting MDCT as a diagnostic modality of high accuracy in this subject. Balci et al. [13] reported a radiographic sensitivity of 67% for the scaphoid fracture. Also, Stevenson et al. [23] revealed that an occult scaphoid fracture can be excluded from the start with the patient returning to regular activity immediately by using MDCT as the initial examination without the need for repeated radiography. Syed et al. [2] showed that scaphoid fracture is common through the middle third (waist) of the bone. In our study, 26 of 32 (81.25%) patients with scaphoid fractures detected at CT were in the waist. Welling et al. [17] reported that proximal pole fractures of the scaphoid, in particular, need surgical treatment within a
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Fig. 6 A 42-year-old female patient came to ER complained of left wrist pain after falling on it. a Posteroanterior and b lateral radiographic image with no detectable fracture. c Axial and d sagittal reformatted CT images demonstrate non-displaced intra-articular distal radius fissural fracture (white arrows)
Fig. 5 A 24-year-old male came to ER complained of left wrist pain after falling on outstretched hands. a Posteroanterior and b lateral radiographic views demonstrate distal radius fracture (yellow arrow) with volar wrist dislocation (green arrow). c Coronal reformatted CT image shows intraarticular distal radius fracture (yellow arrow). d Axial CT image shows intra-articular distal radius fracture (yellow arrow). e Sagittal reformatted CT image reveals intra-articular distal radius fracture with volar displacement (yellow arrow). f 3D reformatted CT image demonstrates intra-articular distal radius fracture with volar displacement (green arrow)
narrow time frame in order to prevent osteonecrosis as the scaphoid takes its blood supply mostly from the dorsal branches of radial artery which enter at the waist of the scaphoid. In our study, we had two patients with proximal pole fracture of the scaphoid. This fracture was missed at radiography and detected at MDCT. So, in keeping with Welling et al. [17], we supported the rapid use of MDCT in acute traumatic wrist
injuries with clinically suspected scaphoid fractures in order to rapidly start treatment and avoid the possibility of any missed fracture and its subsequent complications. The scaphoid fracture was the only carpal bone fracture detected in our study. This result is different from the results of previous literatures [6, 10, 12, 13] which reported fracture of other carpal bones with various prevalence. This difference might be due to a small number of the study population and the prospective type of our study. Our study revealed that the overall sensitivity of radiography in all wrist fractures was 76.9%. This result is higher than the result of Balci et al. [13], which registered 63.7% sensitivity of radiography in all wrist fractures and result of Welling et al. [17], which reported 64% sensitivity of radiography in the examined wrist. This difference might be due to the high prevalence of displaced fracture in our study (65.4%) which was easily detected on radiography and the retrospective type with selection bias in other studies. An interesting finding in our study is that 19 out of 20 missed fractures detected at radiography were non-displaced and one only was displaced. This result reflects that a nondisplaced fracture can be more difficult to detect at
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radiography than a displaced one and the MDCT is of great value in the detection of non-displaced fracture. The average effective radiation dose of radiography was 0.01 mSv and that of MDCT examination was 0.1 mSv. Although the effective radiation dose is higher in MDCT examination than in radiography, the extremity MDCT examination can also be considered as a low-dose examination [24]. Even though there is an inverse relationship between effective radiation dose and image noise, there are some scanning factors in MDCT imaging that offer an excellent image quality with a small radiation dose. These factors involve tube current, tube potential, detector configuration, pitch, gantry rotation time, automatic exposure control, table speed, slice collimation, scanning phases, scan region of interest, scan modes, scan length, post-processing image based filters, metal artifact reduction software, and shielding devices [25]. So the effective radiation dose of MDCT can be reduced by careful choice of scanning parameters and optimizing the scan protocols. This supports the use of MDCT as long as it is indicated for the benefit of the patient. Our study demonstrated that there was no significant difference between the two modalities (P = 0.1347) and both had high consistency (κ = 0.8359) in the detection of acute traumatic wrist injuries. In our study, the radiography was adequate for diagnosis of acute wrist injuries in 38.7% (48/124) and MDCT did not add any diagnostic value. In the remaining injuries, the MDCT was essential either due to non-visible fractures at radiography (24/124) or complicated fractures and required more anatomical detailed (52/124). So our study established that MDCT has two essential roles in acute traumatic wrist injuries. The first, when the radiography is in doubt about the presence of a fracture, MDCT is used to confirm or exclude fractures. The second, when the fracture is detected at radiography and the orthopedic surgeon needs more details about fracture, MDCT is used to better define the extent of injury, provide more clear and comprehensive information about fractures, evaluate severity degree and stability of comminuted wrist fractures, decide between surgery and conservative management and aid in planning for surgery to select the best technique and approach of operation, and display the significant parts of fractures which require specific attention in the process of operation. Our study has a strong point as it is prospective study so avoids selection bias of retrospective study. However, it has some limitations. First is the absence of other carpal bone fractures among our patients, which prevented us from describing the value of MDCT in confirmation or exclusion of carpal bone fractures when there is a clinical doubt. Second is the absence of follow-up data. The third limitation is the use of MDCT results as a gold standard for the study with no histopathological or surgical evidence for the definite diagnosis. MDCT is not a reliable gold standard for the diagnosis of
carpal bone fractures as false negatives have been proven [26]. MDCT might overlook trabecular bone fractures in wrist trauma. The MRI is accepted as a current gold standard for detection of wrist fractures, especially carpal bones [27]. However, MDCT has been proposed to have acceptable sensitivity to detect occult wrist fractures and also superior to MRI for the detection of cortical bone fractures [28]. The incidence of CT false-negatives is possibly reduced by using thin sections and multiplanar reformation [17]. The availability of MDCT in many trauma centers yields an advantage over MRI.
Conclusion The radiography still remains as the first screening tool in acute traumatic wrist injuries due to its wide availability, low radiation dose, and low costs in comparison to MDCT. But in cases where there is a doubt or equivocal primary radiographic findings as in complex distal radius fractures and clinically suspected scaphoid bone fractures, MDCT examination can be used to confirm or exclude the presence of fractures and put a preoperative roadmap if the surgery is decided. So MDCT is complementary to radiography and could not replace it. Acknowledgements The authors express their great gratitude to all staff members and colleagues in the Radiology Department—Zagazig University for their helpful cooperation. They also thank all patients for their patience and support.
Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Ethical approval Institutional review board approval was obtained. Informed consent Written informed consent was obtained from all patients.
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