The diagnostic accuracy of wrist cineradiography in diagnosing scapholunate dissociation

Abstract

Ruptures of the scapholunate ligament (SLL) may cause carpal instability, also known as scapholunate dissociation (SLD). SLD may lead to osteoarthritis of the radiocarpal and midcarpal joints. The aim of this retrospective study was to determine the diagnostic value of wrist cineradiography in detecting SLD. All cineradiographic studies made during a 24 year period were retrieved. All patients who underwent the confirmation method (arthroscopy and/or arthrotomy) and cineradiography were included. In total, 84 patients met the inclusion criteria. Sensitivity, specificity, likelihood ratio, positive predictive value, negative predictive value, and diagnostic accuracy for detecting SLD were calculated for radiography and cineradiography. Cineradiography had a sensitivity of 90%, a specificity of 97%, and a diagnostic accuracy of 0.93 in detecting SLD. Radiography had a sensitivity of 81%, a specificity of 80%, and a diagnostic accuracy of 0.81. Cineradiography has a high diagnostic value for diagnosing SLDs. A positive cineradiography markedly increases the post-test probability of SLD.

Keywords

Fluoroscopy scapholunate dissociation scapholunate ligament wrist arthroscopy wrist cineradiography

Introduction

Ruptures of the scapholunate ligament (SLL) are common wrist ligament injuries (Gelberman et al., 2001). In association with distal radius fractures, the incidence of SLL tears found during surgery is approximately 36% (Geissler et al., 1996; Lindau et al., 1997; Richards et al., 1997). A tear of the SLL may cause a transarticular dissociation known as a scapholunate dissociation (SLD) (Garcia-Elias et al., 1995; Short et al., 2007; Watson and Ballet, 1984). SLD can be classified as dynamic SLD or static SLD (Chennagiri and Lindau, 2013; Cooney et al., 1990; Larsen et al., 1995; Short et al., 2007). Dynamic SLD causes a distortion of the scaphoid and lunate bones only during motion and return to their normal position at rest (Schmitt et al., 2006). This explains why dynamic SLD is frequently missed on conventional radiographs (Adolfsson and Povlsen, 2004; Hohendorff et al., 2012; Koh et al., 2013; Slutsky, 2008). Early recognition and consequently treatment of a dynamic SLD may prevent a static SLD, which in turn, may lead to degenerative attritional changes of the radiocarpal and eventually the midcarpal joint (O’Meeghan et al., 2003; Watson and Ballet, 1984). With a sensitivity of 69% and specificity of 64–68% (Marx et al., 1999), the scaphoid shift test (Watson et al., 1988) has been shown to be a poor test in detecting SLD. Therefore, additional imaging studies are needed for diagnosing or disclosing SLD. To diagnose dynamic SLD suggests the need for a dynamic radiodiagnostic technique. Wrist cineradiography is the only real-time radiological tool that can visualize bones in motion. This should be able to identify the absence or presence of synchronous movements between the scaphoid and lunate within their row. Therefore, cineradiography should be able to investigate the function of the SLL and, consequently, should be able to make a distinction between a dynamic and static SLD.

The aim of this retrospective study was to determine the diagnostic value of wrist cineradiography in detecting dynamic and static SLD.

Methods

This retrospective study was performed at a tertiary care centre for hand and wrist surgery. Records of all consecutive wrist cineradiographies performed in patients with both acute and chronic complaints between July 1987 and May 2011 were reviewed. All patients with suspected carpal instability or wrist ligament injury received a wrist cineradiography during this period. Carpal surgery is considered the best confirmation method for diagnosing SLL injuries (Dohi et al., 2012). All patients who had wrist cineradiography followed by carpal surgery (wrist arthroscopy and/or arthrotomy) were included.

In these patients medical history, radiology reports of the cineradiographies, and reports from arthroscopy and/or arthrotomy were reviewed. We excluded cineradiographies of patients who had prior wrist surgery and patients familiar with skeletal and/or connective tissue disorders (e.g., rheumatoid arthritis). When patients met the inclusion criteria, we reviewed all conventional radiographies of the included patients. Outcomes of wrist cineradiography (primary objective) and conventional radiography (secondary objective) were compared with the confirmation method.

Wrist cineradiography

Wrist cineradiographies were performed by a radiologist following a strict protocol that was implemented ever since our institution started to use wrist cineradiography as a diagnostic tool. The borders of the field of view were defined proximally with the distal radius and ulna at the level proximal to the distal radioulnar joint (DRUJ) and distally with the first third of the metacarpal bones. Movements of the carpal bones were recorded on videotape, DVD, or digitally in picture archiving and communication system (PACS; Philips Medical Systems, Best, The Netherlands). To familiarize the patient with the examination and compare the injured to the non-injured wrist, the non-injured wrist was examined first. To reach a maximum range of motion, passive flexion/extension and radial/ulnar deviation were performed in both lateral and posteroanterior (PA) projections with continuous fluoroscopy. Additionally, we performed the midcarpal shift test in both directions. Cineradiography was considered positive if the movement of the scaphoid and lunate bones was not synchronous and/or a diastasis between the two bones could be provoked (Figure 1 and 2). On the lateral projections, cineradiography was positive when the lunate did not move synchronously with the scaphoid during flexion.

The results of the test were reported and stored in the patient record by the radiologist who performed the cineradiography. In this study, we relied on the radiology reports made by the radiologist.

Conventional radiography

Conventional radiographs were made in PA (Figure 3) and lateral views. All measurements were performed in a picture archiving and information system environment, where all radiographs are stored digitally.

Radiographs were considered positive for SLD when a minimum of one of the following was seen: a widened SL gap (≥ 3 mm) (Kuo and Wolfe, 2008), increased SL angle (≥ 60°) (Garcia-Elias et al., 1995; Megerle et al., 2011), or increased RL angle (≥ 12°). Additionally, the “cortical ring sign”, which is a sign of increased flexion of the scaphoid, was scored on the PA views (Gilula and Yin, 1996).

Surgery

All patients included in this study underwent wrist arthroscopy, arthrotomy, or both. When wrist arthroscopy showed an SLD in most cases an open repair or salvage was performed immediately.

During arthrotomy the SLL was scored as intact, lax, or partially or completely ruptured. An SLL was lax when the SLL was intact but there was a disproportional movement between the scaphoid and lunate bones. During arthroscopy SLL injuries were classified according to the Geissler classification (Geissler, 1995).

No differences between dynamic and static SLD could be made during arthroscopy or arthrotomy, because it was impossible to judge if the secondary stabilizers were intact or not.

To combine the results of arthrotomy and arthroscopy we made the following classification: a Geissler score of I on arthroscopy or an intact SLL during arthrotomy was classified as “no SLD”. A Geissler score of II diagnosed with arthroscopy or a lax or partial ruptured SLL found during arthrotomy was classified as “stage-1-SLD”. A Geissler score of III or IV or a ligament rupture found during arthrotomy was defined as “stage-2-SLD”. When there was a discrepancy, we favoured the findings at arthrotomy over arthroscopy because of poor visibility in a few cases during arthroscopy.

Statistical analysis

Normality of continuous data was tested using the Shapiro–Wilk and Kolmogorov–Smirnov tests and inspecting the frequency distributions (histograms). Homogeneity of variances was tested using Levene’s test.

Descriptive analysis was performed to assess baseline characteristics. For continuous data, mean (SEM) and standard deviation (SD) (parametric data) or medians and percentiles (non-parametric data) were calculated. For categorical data frequencies were calculated.

Differences in RL- and SL-angles and SL distances between patients with and without SLD were compared using the Student’s t-test (parametric data) or Mann–Whitney U-test (non-parametric data). Differences were considered statistically significant when p values were < 0.05.

Sensitivity, specificity, likelihood ratio, positive predictive value, negative predictive value, and diagnostic accuracy for detecting SLD were calculated for conventional radiographs and wrist cineradiographies. For wrist cineradiography and static radiography 2 x 2 tables were made. A logistic regression analysis was performed to model the relationship between the covariates cineradiography, SL distance in millimetres on PA radiographs, and an SLD confirmed with arthroscopy or arthrotomy. To evaluate the goodness of fit of the logistic regression model, Nagelkerke’s R-squared was calculated. Finally, a receiver operating curve (ROC) was calculated for the fitted model.

Results

In almost 24 years, 1645 wrist cineradiographies were made in 829 patients. Only 85 wrists matched our inclusion criteria. In 62 of these wrists conventional radiographs were made. Of the 1560 excluded wrist cineradiographies, 91 cineradiographies were positive for SLD. Baseline characteristics are presented in Table 1.

Table 1.

Baseline characteristics.

Characteristics, N = 85 wrists	Mean (range)
Age, years	39 (19–61)
Gender	N (%)
Men	47 (56)
Women	37 (44)
Side affected	N = wrists (%)
Right	54 (64)
Left	29 (35)
Both	1 (1)
Dominant side affected	N = wrists (%)
Yes	38 (45)
No	20 (24)
Unknown	27 (31)

Surgery

In total, 52 SLDs in 85 wrists (61%, 95% CI 50–71) were found during surgery. Median time between wrist cineradiography and the operation was 107 days.

Intra-operative findings are presented in Table 2. Of the 20 wrists that underwent both arthroscopy and arthrotomy, 12 wrists were diagnosed as a Geissler III/IV (stage-2-SLD) during arthroscopy; in one of these wrists the SLL showed only laxity (stage-1-SLD) during arthrotomy. In one wrist the SLL was not visible during arthroscopy; this wrist was diagnosed with a lax ligament during arthrotomy (stage-1-SLD).

Table 2.

Findings during arthroscopy and/or arthrotomy.

N = 85 wrists	Arthroscopy	Arthrotomy	Arthroscopy and arthrotomy*	Total
No SLD	14	18	1	33
Stage-1-SLD	1	10	8	19
Stage-2-SLD	5	17	11	33
Total	20	45	20	85

Results found during arthrotomy are presented.

Wrist cineradiography

A 2 x 2 table for wrist cineradiography is presented in Table 3. Four of the five false negatives were scored as stage-1-SLD and one was scored as stage-2-SLD during operation (Table 4). The false positive test was scored as a dynamic SLD during cineradiography.

Table 3.

Cineradiography vs the confirmation method.

N = 85 wrists	SLD at confirmation method (+)	SLD at confirmation method (–)	Total
SLD at cineradiography (+)	47	1	48
SLD at cineradiography (–)	5	32	37
Total	52	33	85

Table 4.

Cineradiography vs SLD stage on the confirmation method.

Cineradiography	No SLD	Dynamic SLD	Static SLD	Total
CM
No SLD	32	1	0	33
Stage-1-SLD	4	4	11	19
Stage-2-SLD	1	12	20	33
Total	37	17	31	85

CM= confirmation method; N= wrists

Conventional radiography

Table 5 presents a 2 x 2 table for conventional radiography. Of the eight false-negative conventional radiographs, three were scored as stage-1-SLD and five were scored as stage-2-SLD during operation. Five of these false negatives were found to be positive during wrist cineradiography. All four false positives were scored suspected as dynamic SLD, as the SL distance in these wrists was < 3 mm, but a cortical ring sign or increased SL and RL angles were present.

Table 5.

Conventional radiography vs confirmation method.

N = 62 wrists	SLD at confirmation method (+)	SLD at confirmation method (–)	Total
SLD at conventional radiography (+)	34	4	38
SLD at conventional radiography (–)	8	16	24
Total	42	20	62

Carpal angles and cortical ring sign

Mean SL distances, and SL and RL angles between patients with and without an SLD were significantly different (Table 6). Every measurement apart, including the cortical ring sign, was compared with the confirmation method (Table 7).

Table 6.

Findings on conventional radiographs, patients with vs without SLD.

	SLDMean (SD)	No SLDMean (SD)	p value
SL distance, mm	3.21 (1.51)	1.25 (0.74)	< 0.001
SL angle, °	63.52 (16.76)	47.88 (13.59)	0.001
RL angle, °	8.83 (12.38)	1.03 (14.20)	0.031

Table 7.

Test characteristics of conventional radiography and wrist cineradiography.

	N	Sensitivity	Specificity	LR+	LR–	PPV	NPV	Accuracy
Cineradiography	85	0.90 (0.78–0.96)	0.97 (0.82–100)	29.83 (4.32–205.92)	0.10 (0.04–0.23)	0.98 (0.88–1.00)	0.86 (0.70–0.95)	0.93
Radiography	62	0.81 (0.65–0.91)	0.80 (0.56–0.93)	4.05 (1.66–9.84)	0.24 (0.12–0.46)	0.89 (0.74–0.97)	0.67 (0.45– 0.84)	0.81
SL distance ≥ 3 mm	62	0.52 (0.37–0.68)	1.00 (0.80–1.00)	∞ (NaN–∞)	0.48 (0.35–0.65)	1.00 (0.82–1.00)	0.50 (0.34–0.66)	0.68
SL angle ≥ 60°	62	0.48 (0.32–0.63)	0.80 (0.56–0.93)	2.38 (0.94–6.05)	0.65 (0.48–0.90)	0.83 (0.62–0.95)	0.42 (0.27–0.59)	0.58
RL angle ≥ 12°	62	0.43 (0.28–0.59)	0.85 (0.61–0.96)	2.86 (0.95–8.58)	0.67 (0.51–0.89)	0.86 (0.63–0.96)	0.41 (0.27–0.58)	0.56
Cortical ring sign	62	0.52 (0.37–0.68)	0.75 (0.51–0.90)	2.10 (0.93–4.72)	0.63 (0.45–0.90)	0.81 (0.61–0.93)	0.43 (0.27–0.60)	0.60
After exclusion of patients with an SL distance ≥ 3 mm on conventional radiography
Cineradiography	40	0.85 (0.61–0.96)	0.95 (0.73–1.00)	17.00 (2.49–115.86)	0.16 (0.06–0.45)	0.94 (0.71–1.00)	0.86 (0.64–0.96)	0.90
Radiography	40	0.60 (0.36–0.80)	0.80 (0.56–0.93)	3.00 (1.16–7.73)	0.50 (0.29–0.88)	0.75 (0.47–0.92)	0.67 (0.45–0.84)	0.70

Numbers between parentheses: 95% CI.

SL distances, SL angles and RL angles were measured on conventional radiographs.

LR+ = positive likelihood ratio; LR– = negative likelihood ratio; N = wrists; NaN = not a number; NPV = negative predictive value; PPV = positive predictive value

Twenty-nine of 62 wrists had radiographs of both wrists. Differences in radiographic SL diastasis between the affected and unaffected wrists are shown in Table 8.

Table 8.

Differences in SL distance in wrists with vs without SLD on conventional radiographs

	Mean, mm (SD)	p value
SLD, N = 20
SL distance affected wrists	3.13 (1.68)	0.001
SL distance unaffected wrists	1.56 (0.92)
No SLD, N = 9
SL distance affected wrists	1.03 (0.59)	0.147
SL distance unaffected wrists	1.09 (0.24)

As presented in Table 7, an SL distance ≥ 3 mm had a specificity of 100%; this suggests a static SLD. Results of cineradiography and conventional radiography after excluding patients with an SL distance ≥ 3 mm are shown in Table 7.

Logistic regression analyses

Logistic regression analyses showed that a positive wrist cineradiography test combined with the absolute SL distance (mm) is a good predictor for diagnosing SLDs. The model for predicting the change of an SLD is: P (SLD) = 1/ 1 + e^{-1(-7.88+7.18* cineradiography+ 3.299* radiography)}.

The values for cineradiography are 1 when positive and 0 when negative, and the value of radiography is the SL gap measured in millimetres. The model showed that positive cineradiography (OR 1316; p = 0.01) and SL distance on radiography (OR 27 for each millimetre; p = 0.02) both independently predicted the presence of an SLD. We found a Nagelkerke R-squared of 0.88, meaning that approximately 88% of the variability can be explained by the model.

The corresponding area under the curve (AUC) for this model was 99% (95% CI 96–100), and is presented in Figure 4.

Discussion

This retrospective study shows a sensitivity of 90%, specificity of 97%, and diagnostic accuracy of 93% of wrist cineradiography in diagnosing a static and dynamic SLD combined. A positive cineradiography markedly increases the post-test probability of an SLD.

Radiography had a sensitivity of 81%, specificity of 80%, and diagnostic accuracy of 81%.

This difference in test characteristics between radiography and cineradiography may be due to the fact that cineradiography evaluates the movements of the scaphoid and lunate bones in real time, and therefore should also be able to diagnose dynamic SLDs. After excluding all radiographs with an SL distance ≥ 3 mm, 17 of 20 (85%) SLDs were found with cineradiography. The sensitivity of conventional radiography in this group decreases to 60%. Unfortunately, the secondary stabilizers could not be judged during the confirmation method. Therefore, no true difference could be made between diagnosing a static and dynamic SLD with radiography or cineradiography.

Several limitations of our study merit discussion. First, it was a retrospective series in which surgeons were not blinded to the findings of radiological imaging. Cineradiography was mostly performed after radiographs were taken, so the radiologists who performed cineradiography knew the results of radiography when they were present. This could mean that the diagnostic accuracy of cineradiography could be artificially high because the evaluation of the second test included knowledge about the first test. There was no independent verification of the cineradiology, and so the intra- and inter-observer reliability was not calculated. Only 85 of 1645 wrists met our inclusion criteria. This may be due to the fact that only patients suspected of SLD or with undefined complaints of the wrist were scheduled for surgery. Therefore, the prevalence of SLD (61%) in our study is higher than reported in the literature (31–54%) (Geissler et al., 1996; Laulan and Bismuth, 1999; Lindau et al., 1997; Pliefke et al., 2008). Of the excluded patients 91 had positive cineradiographies. This makes our results susceptible to partial verification bias. Not everyone in our group had a radiograph available for review; this can be explained by the fact that some patients brought their own radiographs from their referring hospital. These were eventually sent back and are therefore no longer available.

Since Arkless (1966) first described cineradiography, only a few studies have been published in which cineradiography has been studied for diagnosing SLDs. In these studies, sensitivity ranges between 43% to 86% and specificity between 64% to 95% (Braunstein et al., 1985; Pliefke et al., 2008).

Some centres recommend magnetic resonance imaging (MRI) for detecting SLDs. The sensitivity of MRI ranges between 41% and 86% and specificity between 46% and 94% (Anderson et al., 2008; Hobby et al., 2001; Haims et al., 2003; Moser et al., 2007; Prosser et al., 2011; Scheck et al., 1999). However, MRI only gives an anatomic evaluation of the SLL and limited information concerning the functional status of the SL joint. A perforation or partial tear in the SLL, although yielding leakage of dye into the neighbouring compartment, is not synonymous with a complete SLL disruption, and therefore MRI could make no distinction between dynamic and static SLD.

Cineradiography is the only dynamic imaging technique available that is able to detect SLD in real time, and therefore it is the only technique that can give information about the functional status of the SL joint. Cineradiography is non-invasive, has relatively low costs, and is widely available. Disadvantages of cineradiography are that it has a learning curve, might be operator dependent, and both patient and operator are exposed to radiation. In the acute stage, physical examination during cineradiography could be painful, which can induce false-negative results.

Conventional radiographs remain essential in the primary work-up for suspected SLD. Positive findings suggest the presence of an SLD. However, due to low sensitivity (60–80%), we recommend cineradiography when an SLD is clinically suspected. Our model has shown to be useful in discriminating which patients have an SLD with an AUC of 99%. However, preferably the model has to be validated in an external dataset.

Cineradiography appears to be a promising and helpful non-invasive diagnostic tool for diagnosing SLD. However, studies are needed to determine the estimated learning curve in making and evaluating cineradiographies. Additionally, inter- and intra-observer variability studies would be useful.

Footnotes

Conflict of interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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