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Jekaterina Gagarina
Sixth year student Riga Stradins University, Latvia
Ardis Platkajis
Associate Professor Riga Stradins University, Department of Radiology, Latvia
PLAUKSTAS PAMATNES TRAUMATISKO BOJAJUMU MAGNETISKAS REZONANSES UN DATORTOMOGRAFIJAS DIAGNOSTIKAS EFEKTIVITATES SALIDZINAJUMS
WRIST TRAUMATIC DAMAGE - MAGNETIC RESONANCE AND CT SCAN DIAGNOSTICS
EFFICIENCY COMPARISON
Abstract
Introduction: Each year in Latvia the number of patients who have been injured after a sports competition, a direct hits and attacks, or vehicle accidents has been diagnosed with wrist traumas. Early and accurate diagnostics
have big influence on the treatment and rehabilitation tactics, reduce the amount and frequency of complications, and shorten the time in the hospital.
Aim: To compare the effectiveness of magnetic resonance and computed tomography diagnostics in the case of traumatic injury of the wrist. Using scientific articles, medical textbooks, atlases and statistics, compare the effectiveness of magnetic resonance imaging and computer tomography in various traumatic lesions and find out which method is more effective.
Materials and methods: Literature review and analysis. Studies and articles published between January 1990 and December 2017. The textbooks published in the time period between January 2007 and December 2017.
Results: In the case of os schapoideum fractures, computed tomography has a higher specificity, but the magnetic resonance - higher accuracy and better PPV and NPV. The sensitivity of both methods is the same. Both methods are effective in detecting other lesions at the os schapoideum, but false positives results in MRI diagnostics are possible. Triangular fibrocartilage complex lesions in computed tomography with contrast have a higher specificity, but magnetic resonance sensitivity, which sometimes manifests itself as hyperdiagnostics. MRI is an unambiguously effective method for diagnosing DISI and VISI, as it gives a presentation of both the presence of bone dislocation and the changes in the ligaments. In the cases of wrist dislocations - CT is preferable because it allow the identification of the bone positioning in three planes and demonstrate the dislocation with 3D CT reconstructed images. CT is also a better method for identifying os schapoideum complications. In other bone lesions, computer tomography showed itself to be an effective and quick method for early diagnostics
Conclusion: Magnetic resonance does not have a clear benefit for the diagnosis of wrist injuries. Computed tomography is a better method for os schapoideum complications, other carpal bone fractures and cases of wrist dislocations.
Key words: wrist, bones, ligaments, fractures, tears, computed tomography, magnetic resonance Atslegas vardi: plaukstas pamatne, kauli, saites, luzumi, plisumi, datortomografja, magnetiska rezonanse
INTRUDUCTION
Frequency of carpal fractures in adults using Edinburgh epidemiological data about fractures from September 2010 to August 2011 show that carpal fractures are relatively frequent and are 2,8% of all fractures with morbidity of 37,5 / 105 people per year [Table 1 and 2] [8]. Data for the last 60 years does not particularly vary and this prevalence of fractures fluctuates between 2% and 3% of all the fractures [9, 12]. The average age of the patients varies from 35 to 40 years, and there is a predominance for men. Falls from a standing height account for almost two thirds of all injuries, other types of injuries include sports injuries (9,5%) [56], direct beatings or assaults and road accidents [22, 25]. Constantly documenting that os scaphideum and os tri-quetrium bone fractures account for more than 90% of
all carpal fractures, while os hamatum, os pisiforme, os lunatum, os capitatum, os trapezium and os trape-zoideum trauma cases are rare [Table 3]. Carpal instability is widespread among young and middle-aged people. Although almost 30% of all traumatic injuries suffer from wrist instability, epidemiological data for carpal instability are not available [43]. Studies conducted by Dobyn et al. show that 10% of all carpal injuries are based on instability [49]. There is no clear connection between carpal instability and other trauma, and there are no signs of morbidity [55]. Almost a quarter of these injuries are not diagnosed or reported in a timely manner, which can delay the diagnosis and subsequently lead to worse results and treatment outcomes [47].
Table 1.
Epidemiology of Fractures Treated in a 1-Year
Fractures % of all fracture types n/100000/per year Mid-age [years] Patient % with age >65 Patient % with age >80 % men/woman
194 2.8 37.5 38 7.7 1.5 64/36
Table 2.
Epidemiology of Fractures Treated in a 1-Year Period. Age and Gender_
Gender Mid-age [years] Fractures % of all fracture types n/100000/per year Multiple fractures % Open fractures % Cause
Men 16-35 87 5.4 95.8 4.6 0 35,6% sport, falls 33,3%
Men 36-64 32 2.8 27.9 12.5 0 62,5% falls, 12,5% vehicle accident
Men >64 6 1.1 15.5 0 0 100% % falls
Woman 16-35 19 3 20.1 0 0 84.2% falls, 5.3% sport
Woman 36-64 41 3.1 33.9 9.8 0 falls 87,8%, sport 4,9%
Woman >64 9 0.5 15.5 11.1 0 88,9% falls, 11,1% direct hits and attacks
Table 3.
Bone fracture incidence
Gaebler et al [16] Rockwood and Green's Fractures in Adults [8]
os scaphideum [%] 68.2 72.7
os triquetrum [%] 18.3 22.7
os trapezium [%] 4.3 <1
os lunatum [%] 3.9 -
os capitatum [%] 1.9 -
os hamatum [%] 1.7 2.1
os pisiforme [%] 1.3 1.6
os trapezoid [%] 0.4 -
STUDY MATERIALS AND METHODS
Method of investigation: Review and analysis of literature.
Study materials: Existing scientific articles and clinical reports in databases Pubmed, ScienceDi-rect, Cochrane, DynaMed Plus and Scopus. Existing textbooks on visualization, traumatology and anatomy in databases Wiley-Blackwell and ClinicalKey.
Period of publication of studies and articles: from January 1990 to December 2017.
Period of publication of textbooks: from January 2007 to December 2017.
Keywords: carpal, bones, ligaments, fractures, fissures, CT scan, MRI.
Assessment of relevant publications: number of patients; diagnostic image sensitivity, specificity and accuracy; advantages and disadvantages of the image diagnostic methods.
RESULTS OF THE STUDY
Diagnosis of fractures in os scaphoideum is proven by a combination of clinical history, objective examination and evaluation of radiography. However, trauma cannot be detected for up to 30-40% of patients in the assessment and patient study with standard X-rays and therefore are classified as suspected fractures [4, 17]. According to the recommendations of the American Radiological College, patients suspected with os schapoideum fractures and negative X-rays should undergo an early MRI scan to determine an immediate diagnostic diagnosis [5]. According to the new German interdisciplinary recommendations S3 based on evidence, it is nevertheless recommended to use CT in this case. These experts claim that CT is better than MRI because it has better spatial resolution to show the presence of fractures and better diagnostic specificity (> 95%, in contrast to 80-90%, respectively) [52]. Despite the fact that negative X-ray images are negative in determining bone fractures, both CT and MRI are cost-effective in reducing both costs and morbidity [28]. Gregory et al. analysing 47 patients with suspected bone fractures using 2-week radiographs and / or MRI as the reference standard, CT showed a sensitivity of 94,4% and a 100% specificity with a negative predictive value of 96,8% and a positive predictive value and 100% [20]. It was proven that CT is also useful for investigating other carpal fractures. In a study of 28 patients with a possible fracture, who underwent CT, 36% of patients were diagnosed with distal radius or other
wrist fractures [60]. Stevenson et al. made a retrospective analysis of 84 patients suspected of fractures, who underwent CT for 14 days after trauma. Fifty-four scans were normal. Of the 30 abnormal scan data, the authors found that 7% were hidden fractures, 18% were other hidden fractures (triquetrum, capitatum, luna-tum), and 5% were distal radius fractures. In total, about one third of the CT data suspected in hidden fractures revealed other carpal injuries. Orthopedic Imaging A Practical Approach stresses out that the tomography proved to be very effective and right now CT is the chosen method. This method was equally useful for assessing the healing of cracks and post-traumatic complications, especially if the radiographs were not convincing [19]. In 2005, Temple et al compared CT and simple X-ray images (images of 11 cadavers with fractures were compared). As a result, the sensitivity of the method to determine the fracture = 100%, the sensitivity to determine if the fracture was moved > 1 mm = 50%, the specificity for determining whether the crack changed > 1 mm = 89% [57]. But one study showed that for fractures with dislocation CT has a low positive predictive value (PPV = 13%), indicating that many of the positive results of this test are false positives. Sensivity was 72%, specificity 80%, accuracy 80% and NPV 98%. Nguyen et al in a study with 118 patients suspected of fractures and normal or doubtful X-rays performed CT scans and found 26 fractures. 3 scaphoid fractures were found with CT in 6 patients with doubtful primary radiography. 23 scaphoid fractures were detected by CT in 102 patients with X-ray. If a fracture is suspected, the MRI is considered to be the best method, although some institutions have limited access to it, and there are contradictions in economic efficiency. In one study, an MRI scan was performed within 72 hours after injury in 32 patients with suspected fractures, and the sensitivity of MRI and specificity were found to be 100%, potentially saving $ 7,200 per 100,000 of population, avoiding unnecessary immobilization and testing [18]. In another randomized controlled trial, 84 patients with suspected fractures were included to have an early MRI and to discharge patients without damage or a standard reassessment at the clinic 10-14 days after injury [45]. They found no difference between the two groups in terms of average cost, pain, patient satisfaction. Although MRI is the most successful secondary diagnostic image method, it was found that PPV is only 88% [Table 4] - Ring and Lozano-Calderon [48] performed analysis to determine
12 Wschodnioeuropejskie Czasopismo Naukowe (East European Scientific Journal) #5(33), 2018 3ÜÜ the diagnostic properties of various secondary visualization methods that were used to assess the presence of hidden fractures.
Table 4.
Ring D, Lozano-Calderon S. Imaging for suspected scaphoid fracture_
Sensivity [%] Specificity [%] Accuracy [%] PPV [%] NPV [%]
CT (n = 8) 94 96 98 75 99
MRI (n = 22) 98 99 96 88 00
As a result, the NPV of MRI was 88%, which means that approximately 12% of patients suspected of scaphoid fractures undergo MRI, and the result is interpreted as a fracture when it was not actually a fracture. In 2012, MRI analysis performed on healthy people also showed a possible false positive MRI scan with benign anomalies diagnosed by some radiologists [11]. In this study, it was concluded that MRI is not a suitable standard to verify that patients with suspected fractures actually do have fractures. Khalid et al in their own study included 611 patients with possible clinical damage and normal X-ray images, MRI was performed within 2 weeks after trauma. 269 patients had no carpal
injuries, 272 had acute bone lesions (including fractures of os schapoideum), 23 had acute soft tissue lesions, and 47 showed other carpalar pathologies [30]. Another predicted cohort study that again used 6-week radiographs as a standard showed that CT and MRI were comparable diagnostic measures to determine the true cases of fractures where fractures were only suspected. As a result, CT has 76% PPV compared to 54% of MRI [36]. In the meta-analysis of Yin et al included 41 different studies with a total of 1826 patients, they showed sensitivity and specificity of CT are 93% and 99%, respectively; and accordingly 96% and 99% for MRI [Table 5] [63].
Table 5.
Yin Z.G., Zhang J.B., Kan S.L., et al. Diagnosing suspected scaphoid fractures: A systematic review and meta_analysis_
Sensivity [%] Specificity [%]
CT 93 99
MR 96 99
Mallee, W. et al. in the perspective 2011 study [36] compared the results of CT and MRI in 40 patients with suspected bone fractures and negative primary radiography showed following result: MRI sensitivity = 67%, specificity = 89%, accuracy = 85%. CT sensitivity = 67%, specificity = 96%, accuracy = 91%. Important complications of bone fracture are avascular necrosis (up to 13% of cases), partial avascular necrosis and absence of growth, which can occur if the fracture has not been seen or treatment was insufficient (up to 18% of cases) [31]. Therefore, early and final detection of a fracture is necessary. Although MRI is used to diagnose avascular necrosis of the bone, it has not been established that it is better than CT to assess the incompatibility of the fracture, wrong union [38, 41]. In one of the studies non-unionof os schapoideum and AVN CT diagnostics with a 100% specificity was recorded, but with a sensitivity of 60% and an accuracy of 74% [54]. CT is also cheaper and more affordable in many centers. Os scaphoideum avascular necrosis usually occurs 3-6 months after injury, when the affected fragment showed an increased density. Since conventional radiography sometimes cannot demonstrate this, it is recommended to use CT scans as a valuable aid. Patients with delayed unionor non-unionare more susceptible to osteonecrosis, although sometimes despite this spontaneous recovery may occur. Depending on the stage of the disease, CT can see subcondular sclerosis and cyst formation, then collapse and, at the end, secondary osteoarthritis [31]. MRI with intravenous contrast is used in an early diagnostic process to assess the viability of the proximal fragment. It is considered non-
viable if the hypo intense signal is distributed in the affected area in the T1 sequences and there is no improvement after administration of gadolinium [2].
If the previous X-rays of os pisiforme did not show pathology, but the patient still had a clinical suspicion of Fleege os pisiforme fracture, colleagues emphasized that CT scanning is the chosen method of early diagnosis [13].
Both CT and MRI are used if missed Os hamatum fractures are suspected [29], now on a regular basis CT with sagittal reformation are made for wrist axial parts. Scheufler et al reported a sensitivity of 71% for conventional X-rays, however CT showed 100% sensitivity [51]. Although MRI is not indicated in the evaluation of patients suspected of this fracture, this may be useful if the initial normal X-ray and CT scan did not reveal this trauma [19]. If the doctor has a convincing suspicion of os hamatum damage, despite the usual radiographic findings, the next choice for testing is computed tomography [3].
Computed tomography and magnetic resonance methods are used for hidden Os capitatum fractures [1, 10]. But Calandruccio and Duncan [7] reported isolated os capitatum fractures in patients whose initial X-ray images were considered normal. The treatment was delayed until the fracture was diagnosed with MRI. In result, for these fractures the advantage is for MRI, in order to more accurately and quickly confirm the hidden fracture.
Os trapezoideum fractures associated with another fracture in one third of cases. In most cases, without a
dislocation, but if so, then it can occur in both directions. Diagnosis of CT and MRI is required in more than 80% of cases [27]. A simple X-ray is often not enough and CT diagnostics is preferable for the final diagnosis [40].
Os trapezium fracture occurs in connection with a fracture or dislocation of the os hamatum [26]. If there is a suspicion of a fracture, but a X-ray is not enough to prove it, a CT scan can quickly confirm the diagnosis and give advice for further tactics. [14]
CT will provide the most accurate information about os lunatum fractures, as well as all changes in osteonecrosis, which may differ from the primary fracture or secondary fracture associated with bone fragmentation. Since X-rays can often be completely normal and only CT can detect a thin linear fracture. As well as CT scanning is preferred for crushed bones [15]. MRI demonstrates anomalies in bone structure showing a reduced signal intensity associated with T1sequences images [19].
Os lunatum avascular necrosis (Kienbock's disease) is often caused by wrist traumas, such as brittle fracture that can be manifested as os lunatum cessation of blood supply. Although the traditional classification of Lichtman was developed on the basis of X-rays and MRI and was useful in planning treatment [14], CT can help in early diagnosis [34]. But, in particular, the MRI evaluation will be useful in assessing the progression of the disease. Having T1 sequences images Kienbock's disease os lunatum must be uniformly dark (at low signal intensity), but in case of a fracture the signal will be heterogeneous [39] and if in the early stages of the disease the usual X-rays are normal, then the T1 sequence MRI can detect low intensity of the signal throughout the bone. In turn, the T2 sequence MRI correlates with predictions evaluating the increase in signal intensity, which is directly proportional to the vascular system process [6].
Right now if there is clinically strong suspicion of os triquetrum fracture, and there are no signs of fracture with normal X-rays or they are doubtful, CT is the chosen diagnostic method [19, 37]. Secondary imaging methods are often not needed, since primary CT is the preferred method for os triquetrum fractures. Bone transverse fracture is diagnosed as part of the perilunar dislocation, occurring in 12-25% of cases [33, 61]. CT is the best way to determine the size of the detached fragment and the degree of damage, which will affect the use of a conservative or surgical approach [40]. MRI is used in cases where fracture uniondoes not develop and there is a suspicion of simultaneous scapho-lunate or lunotriquetral ligament rupture [46].
In triangular fibrocartilage complex damage CT with contrast gives us sensitivity: 92% and specificity: 94% [2]. Contrast tomography CT - for the third type round defect near ulna fovea and for the fourth type -big defect near shoulder joint was a high specificity and a positive predictive value for the detection of a rupture. Specificity and positive prognostic values were respectively 90% and 89% for types 3 and 100% and 100% for type 4, respectively, while sensitivity was 35% for type 3 and 22% for type 4 [23]. CT arthrography is very sensitive to the determination of the central rupture of
TFCC, but is not accurate for determining peripheral ruptures [14]. Many asymptomatic wrists have a positive MRI detection [14]. In the radial joint, TFCC is inserted into the hyaline cartilage, and not into the cortex; which results in an average signal intensity representing the cartilage between the radial cortex of low intensity and the intensity of low intensity signals. The radial hyaline cartilage should not be mistakenly interpreted as a rupture. Areas in which the increased intensity of the signal on the hyaline cartilage surface can be distinguished from the rupture, because they do not have high-signal MRI images with contrast medium such as T2 [2]. Image appearance of TFCC MRI is a hypo-dynamic disk in all sequences. However, the radial attachment of TFCC often shows the intensity of the signal from medium to high, which can be a potential error [59, 64]. The MRI results are variable with respect to the location of the TFCC ruptures. Sensitivity to central defects is 91%, radial defects - from 86% to 100%, and ulnar defects - from 25% to 50% [44]. Metaanalysis from 0.5 to 1.5 Tesla MRI, conducted in 410 patients tested for TFCC rupture, showed sensitivity, specificity and accuracy of 83%, 80%, and 81%, respectively, compared with arthroscopy [24]. New magnets with a higher resolution, 3.0 Tesla magnet improved TFCC rupture detection, with sensitivity and specificity that were approaching 86% and 100% respectively. Magnetic resonance is more susceptible to the discovery of TFCC, but it results in a number of false positive results due to microperforation occurring in 7% to 35% of the population [35]. MRI arthrography improves sensitivity - sensitivity: 96%, specificity: 100% [2]
Perilunate dislocation is the most common form of carpal dislocation and includes a traumatic spectrum that can include ligament injuries, as well as bone fractures. The literature shows that from 16 to 25% of the perilunate dislocation was initially ignored [21]. CT is mandatory for assessing the full extent of bone injuries. This must be done urgently, taking into account the risk of lunate avascular necrosis [31]. Similarly, the dislocation can be identified by evaluating arc II formed by os schapoideum, os lunatum and os triquetrum distal bulging surface changes. Dislocation can also be effectively demonstrated in CT, in particular, in 3D CT reconstructed images [19].
DISI (Lig. Scapholunatum injury) is a condition in which os lunatum unusually tilts in relation to the radius. This instability is the result of the interruption or weakening of the scapholunatum ligament. The method of computed tomography is used instead of radiography to assess the bone mutual relationship [62]. MRI is used more often for more accurate evaluation of lig. Scapholunatum. Usual MRI studies on magnets of 1.5 Tesla show that sensitivity varies from 50% to 93%, specificity from 86% to 100%, and accuracy from 77% to 87% [58]. Hobby et al. carried out meta-analysis in which the use of 0.5-1.5 Tesla MRI was used to detect inner ligament ruptures. Six studies about lig. Scapholunatum rupture diagnostics in 159 patients showed MRI sensitivity, specificity and accuracy of 70, 90, 85%, respectively, compared with arthroscopy [24].
Two studies about VISI (Lig. Lunotriquetrum injury) showed that MRI is not a measure to be trusted
when diagnosing the integrity of lig. Lunotriquetrum. From a number of cases, using arthroscopy as a gold standard, MRI showed a general 50% sensitivity, 100% specificity and 80% accuracy [50] and sensitivity 52%, specificity 46% accuracy 49% [53]. Similarly, in six studies of lig. Lunotriquetrum rupture assessment in 142 patients with MRI, sensitivity, specificity, and accuracy were identified at 56%, 91%, and 82%, respectively, relative to arthroscopy [24]. Another experimental use of 3.0 Tesla MRI improved susceptibility to ligg. Scapholunatum and Lunotriquetrum ruptures, by 89% and 82% respectively [35]. Compared with MRI, CT arthrography allows get increased spatial resolution, reduced artifacts movement and can be diagnosed
with an accuracy of > 95% for inner ligaments and TFCC ruptures [32].
Carpal traumas. Summary.
Based on the results of the studies in Table 6, it can be concluded that the sensitivity of computer tomography ranges from 67 to 100 percent, specificity from 96 to 100 percent, accuracy from 80 to 98, PPV from 13 to 100 percent, and NPV from 96.8 to 99. In contrast, the sensitivity of magnetic resonance ranges from 67 to 100 percent, specificity from 89 to 100 percent, accuracy from 85 to 100, PPV from 54 to 88 percent, and NPV 100.
Schmitt Gregory Dias Temple Gaebler Ring un Lozano-Calderon Mallee Yin
CT MR CT CT CT MR CT MR CT MR CT MR
Sensivity [%] 95 8090 94,4 72 100 100 94 98 67 67 93 96
Specificity [%] 100 80 100 96 99 96 89 99 99
Accuracy [%] 80 98 96 91 85
PPV [%] 100 13 75 88 76 54
NPV [%] 96,8 98 99 100
Table 6.
Os schapoideum fractures
Table 7 clearly shows that literature and research data prefer computed tomography as an accurate and convenient diagnostic method for other carpal bones.
Table 7.
Other carpal bone fractures
CT MR Comments
Os pisiforme + Fleege and colleagues say that CT Scan is an optional method for early diagnosis
Os hamatum + +I- Scheufler et al reported 100% sensitivity of CT and prefer MRI if negative CT and positive symptomatic
Os capitatum - + Calandruccio un Duncan prefer MRI for isolated os capitatum fracture
Os trapezoideum + +I- Mordechai (Principles and Practice of Wrist Surgery) prefer CT, but CT and MRI are equally effective
Os trapezium + - Azar - Campbell's Operative Orthopaedics gives CT an advantage
Os lunatum + - Freeland et al recommend CT for multiple bone fractures
Kienböck'a sllmlba +I- +I- CT for early diagnosis MRI will be useful for disease progression rate
Os triquetrum + +I- CT for fragment size and damage grade rating MRI - when the fracture is not developed and there is a suspicion of ligament damage
According to the results of the studies listed in Table 8, it can be concluded that the sensitivity of computed tomography varies from 22 to 92 percent, specificity from 90 to 100 percent, PPV from 89 to 100 percent. On the other hand, the sensitivity of the MRI is 83 to 96 percent, the specificity is 80 to 100 percent, and the accuracy is 81. In case of VISI and DISI CT scan can only give an idea of the bone mutual relationship, an accurate diagnosis requires MRI conclusion about
the state of carpal ligaments. From the literature and research data, it can be concluded that for DISI diagnostics with MRI the sensitivity of the method is from 50 to 93 percent, specificity from 86 to 100 and accuracy from 77 to 87 [Table 9]. VISI diagnostics with MRI shows sensitivity from 50 to 82 percent, specificity from 46 to 100 and accuracy from 49 to 95. But CT in Lee's study shows a better accuracy of 95% [Table 10].
TFCC damage diagnostics
Table 8.
Bille B Hisao Hobby Magee Randa et al
CT With contrast CT With contrast MR MR MR With contrast
Sensivity [%] 92 22-35 83 86 96
Specificity [%] 94 90-100 80 100 100
Accuracy [%] 81
PPV [%] 89-100
Notes Damages type 3 and 4 0,5 - 1,5 Tesla MR Many false positive results due to micro perforations, occurring in 7% to 35% of the population
Table 9.
DISI MRI diagnostics_
Rominger Hobby
Sensivity [%] 50-93 l0
Specificity [%] 86-100 90
Accuracy [%] ll-8l 85
Table 10.
VISI diagnostics_
Rominger Hobby Schweitzer Magee Lee
MR MR MR MR CT With contrast
Sensivity [%] 50 56 52 82
Specificity [%] 100 91 46
Accuracy [%] 80 82 49 95
Notes 0,5 - 1,5 Tesla MR 3.0 Tesla MR
CONCLUSIONS
In the case of os schapoideum fractures, computed tomography has a higher specificity, but the accuracy of magnetic resonance, PPV and NPV are better. The sensitivity of both methods is the same. Both methods are effective in detecting other injuries in os schapoideum fracture clinics, but MRI results can be false positive. In turn, CT is the best method for detecting os schapoideum complications. Computed tomography has proven to be an effective and rapid method of early diagnosis with other carpal fractures. In cases of Triangular fibrocartilage complex injuries computed tomography with contrast has a higher specificity, but MRI has higher sensitivity, which is sometimes manifested in hyperdiagnosis. In cases of carpal dislocations CT is preferable because it allows to identify the mutual relationship of the bones in three axis and to prove dislocation using 3D-reconstructive CT images. MRI is an unambiguously effective method for diagnosing DISI and VISI, as it gives an idea about the presence of bone dislocation, as well as changes in ligaments.
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