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1 Department of Radiology, University General Hospital, C.E.P. Quesada Sanz
c/Dr. Quesada Sans s/n, Murcia 30005, Spain.
2 Department of Traumatology, University General Hospital, Murcia 30005,
Spain.
3 Department of Biostatistics, Faculty of Medicine, University of Murcia,
Espinardo, Murcia 30100, Spain.
Received December 10, 2002;
accepted after revision July 9, 2003.
Address correspondence to J. D. Berná
(jdberna{at}um.es).
Abstract
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MATERIALS AND METHODS. Panoramic (orthopantomographic) and conventional radiographs of 90 patients with acute or chronic wrist trauma were reviewed retrospectively. Images were analyzed and reviewed independently by four observers: two radiologists and two traumatologists. The kappa statistic was used to calculate intraand interobserver agreement and the correlation between the two imaging techniques.
RESULTS. 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.
CONCLUSION. The panoramic examination of the wrist is a useful technique for the diagnosis and follow-up of scaphoid fractures. Its use is recommended as a complement to conventional radiography in cases with inconclusive findings.
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In cases of clinically suspected scaphoid fracture and negative or equivocal findings on conventional radiographs, several different imaging methods to increase the possibility of detection of these fractures are in current use. Among these are bone scintigraphy [5, 6], CT [7], MRI [8, 9], and sonography [10, 11].
The panoramic technique (orthopantomography) is widely used in the assessment of the dentomaxillofacial area. In 1991, we reported the first study of panoramic radiographs of the carpus [12], and in a second article [13], we reported that the panoramic technique is a useful complement to conventional radiography for the investigation of scaphoid fractures and nonunions. Since that second study, the number of patients evaluated with panoramic radiographs of the wrist has increased considerably. In this study, the role of panoramic radiography of the wrist is analyzed and correlated with that of conventional radiography, and inter- and intraobserver agreement is evaluated.
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The 90 patients in this study were separated into three groups: Group 1 included 27 patients with acute trauma and with suspected scaphoid fracture seen on conventional radiographs. The panoramic study and a conventional radiographic examination were performed within minutes of each other, between 1 and 3 weeks after injury (mean, 12 days); in all cases, both panoramic and conventional radiographic examinations were repeated 3–4 weeks later. Group 2 comprised 41 patients with a history of wrist trauma and scaphoid fracture revealed in all cases on the initial panoramic examination. In one of these patients, the initial conventional radiograph was negative. Panoramic and conventional radiography was performed between 1 week and 20 years after the injury. Group 3 contained 22 patients with antecedents of surgery for scaphoid fracture (bone graft in 17 patients and fixation with screw in five patients), and the panoramic examination was performed between 1 month and 3 years after injury. In 17 patients in groups 2 and 3, radiographic follow-up took place between 2 and 19 months (mean, 5 months 14 days). In three patients, a new bone-grafting operation was performed because of evidence of nonunion. Patients in groups 1 and 2 with scaphoid fractures received conservative treatment.
The protocol for radiography of the wrist consisted of four radiographic
projections (posteroanterior, lateral, oblique in pronation, and ulnar
deviation) and a single posteroanterior panoramic projection in all patients.
For the clarification of some cases (
20%), the variant of the standard
posteroanterior panoramic projection was performed. The panoramic projections
have been described elsewhere
[12]. The Orthoralix SD Ceph
(Philips Medical Systems, Monza, Italy) was used for panoramic studies of the
wrist. Before the study, we designed and perfected a device
[14] to achieve the
appropriate positioning and immobilization of the extremity. With the patient
sitting, standing, or preferably lying down, the standard posteroanterior
panoramic projection was made with the forearm vertical and the hand in
supination or with the wrist placed in a sagittal plane parallel to the
sagittal sinus of the patient. The variant of the standard posteroanterior
panoramic projection was performed using approximately 10° of rotation of
the wrist toward the radial side. The panoramic images were obtained by using
60–64 kV and 4–6 mA. Rotation time was always 12 sec.
The initial diagnosis was made by one of the authors of this study and by a radiologist. Findings of the radiographic examinations were assigned to the following categories: negative examination, suspected scaphoid fracture, and scaphoid fracture. These cases were graded using the Herbert and Fisher classification [15]. On the basis of several studies [1, 15–17] and of our own experience, we established the following diagnostic criteria: delayed union (fracture type C), failure to unite within 3–5 months after injury; and nonunion (fracture type D), evidence of the presence of a clear gap at the fracture site more than 5 months after injury. There were two subtypes: fracture type D1, unaltered spatial geometry of the scaphoid; and fracture type D2, a loss of bone mass and a change of shape and volume of the scaphoid. "Doubtful union" was defined as having no evidence of radiographic signs of union or nonunion; "union" was defined as having trabeculation or osseous bridges observed at the fracture line and, in the cases in which surgical intervention had occurred, as lacking evidence of radiolucency around the implant or of loosening of the implant. The final diagnosis was established by consensus of the authors of this study.
Observer Evaluation of Examinations
From the radiographs of the 90 patients in this study, 30 conventional
radiographic and 30 panoramic examinations were randomly extracted and placed
in numbered envelopes, with the conventional images separated from the
panoramic images (30 sets of conventional radiographic and 30 sets of
panoramic images). On each envelope, we wrote the time that had elapsed
between the trauma and the radiographic examination. In surgically treated
cases, the type of surgical intervention and the time elapsed between surgery
and radiographic examination were also given.
Evaluation of these patients was performed by four observers: two traumatologists with 5 and 20 years' experience and two radiologists with more than 25 years' experience each. None of the observers had any connection with or foreknowledge of any of the radiographs selected or any training in the panoramic technique used for wrist study. For this reason, we provided a training session for each observer for uniformity of interpretation, using various examples of panoramic examinations of the wrist that were not included in the series of examinations that they were later to evaluate for our study. To avoid errors during their interpretations and generally to make their task easier, we made available to them on paper details of the diagnostic variables previously established and drawings of the classifications of scaphoid fractures.
Review of the images was performed twice by the four observers in randomized fashion and independently of each other. The first review was carried out in two sessions: in the first session, the 30 sets of conventional radiographs were reviewed, and on the following day, 30 sets of panoramic radiographs of the wrist were reviewed. The second review took place 2 months later, when each set was reviewed in a different order.
Statistical Analysis
We used software (SPSS for Windows, Statistical Package for the Social
Sciences, Chicago, IL). The level of agreement of each patient's examination
(conventional and panoramic) was analyzed by obtaining the kappa coefficient
[18] and the percentage of
agreement between the two imaging methods, and the two kappa coefficients were
compared using the Student's t test. A p value of less than
0.05 was considered to be a statistically significant difference.
We also used the kappa coefficient to study inter- and intraobserver agreement by comparing levels of agreement between the two techniques. A kappa value of 0.20 or less indicated slight; 0.21–0.40, fair; 0.41–0.60, moderate; 0.61–0.80, good; and 0.81–1.00, very good agreement.
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Table 2 shows the cases of scaphoid fractures detected at initial and final diagnoses on both panoramic and conventional radiography. The Herbert and Fisher classification [15] was used. Initial panoramic examination revealed seven more type A2 fractures (Fig. 3A, 3B, 3C) than the conventional radiographic examinations and two type C fractures (Fig. 4A, 4B), one type D1, and two type D2 fractures that were not clearly shown on later conventional radiographs. Agreement between initial and final diagnoses using the two imaging techniques was moderate for conventional radiography, with a kappa value of 0.49 and a percentage of agreement of 53.1%, and was very good for the panoramic examination, with a kappa value of 0.88 and an agreement percentage of 89.9%. Statistically very significant differences (p < 0.001) were found between the two techniques.
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Overall interobserver agreement for conventional radiography was moderate
(
= 0.45, 54.8%). Interobserver agreement for the panoramic examination
was good ( = 0.80, 90%). There was a very significant difference
between kappa values for the two imaging techniques (p < 0.001).
Overall intraobserver agreement for conventional radiography was good (
= 0.61, 71.6%). Intraobserver agreement for the panoramic examination was also
good ( = 0.80, 90%). A significant difference (p < 0.001)
between kappa values for the two techniques was seen. The panoramic
examination of the wrist was well tolerated by all patients.
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The panoramic technique is widely used for the study of the dentomaxillofacial area. Its use has also been described for study of the wrist [12, 13]. Panoramic examination of the wrist permits more detailed visualization of the scaphoid bone than does conventional radiography and thus facilitates depiction of the fracture line. The results of our study clearly show that the panoramic examination of the wrist is superior to conventional radiography in the evaluation of patients with different clinical conditions (suspected scaphoid fractures, scaphoid fracture, or antecedents of surgery). The panoramic examination ruled out scaphoid fracture in 74% (20/27) of patients with suspected scaphoid fracture on conventional radiographs. The panoramic examination also revealed a greater number of fractures, 21.4% more (12/56), especially in cases of undisplaced type A2 fractures according to the Herbert and Fisher [15] classification, and also showed more cases of delayed union, nonunion, and union. A combination of findings of the clinical examination and of those supportive of the fracture as seen in the panoramic examination was considered to be diagnostic.
There are two drawbacks to the panoramic examination: images obtained in patients with marked lack of wrist flexibility are unsatisfactory; in cases of plaster cast–type immobilization, the plaster cast must be removed before the panoramic examination. Correct positioning of the wrist and immobilization of the limb are essential for achieving a clear image of the wrist. In some cases, such as in Figure 3C, blurring is observed centrally because the positioning device is an artifact in itself. For the purpose of minimizing blurring, all panoramic examinations of the wrist are now performed with the patient in a supine position. The support device, now in the commercialization phase, is the key factor in achieving successful panoramic images of the wrist.
The statistical data of our study show greater agreement (90%) in the panoramic wrist examination than in conventional radiography (53%). Inter- and intraobserver agreement was also higher for the panoramic examinations. These findings indicate that the panoramic examination is more accurate than conventional radiography in the diagnosis of scaphoid lesions. Therefore, the panoramic procedure is clearly indicated as a complement to conventional radiography in cases in which the conventional radiographic findings are inconclusive, and it can also be helpful in the follow-up of fractures of the scaphoid.
Imaging algorithms have been proposed [3] for the evaluation of suspected acute scaphoid fracture and avascular necrosis, delayed union, or nonunion, although it was acknowledged that it was difficult to propose an imaging strategy that would be universally applicable. In our hospital, for several years now, orthopedic surgeons have requested panoramic radiography whenever the findings of conventional radiography suggest a possible but doubtful diagnosis of scaphoid fracture or nonunion [13].
The panoramic examination of the wrist is a simple, rapid, economical procedure that facilitates the detection or exclusion of fractures. We recommend this procedure as a complement to conventional radiography for the clarification of inconclusive conventional radiographic studies.
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