Incorporating Cone-Beam CT Into the Diagnostic Algorithm for Suspected Radiocarpal Fractures: A New Standard of Care?

OBJECTIVE. The purpose of this study was to assess the result of adding cone-beam CT to the standard imaging algorithm for patients with suspected radiographically occult traumatic radiocarpal fractures. SUBJECTS AND METHODS. A prospective review was performed on all patients who had cone-beam CT investigation of acute wrist pain after normal initial radiographs. Patients with no identified fractures were clinically reassessed and referred for MRI if concern for a fracture persisted. RESULTS. In all, 117 patients were assessed; 50.4% had fractures identified with a total of 67 radiographically occult fractures. One fracture was identified on MRI that was not seen on cone-beam CT. Cone-beam CT had sensitivity of 98.3% (95% CI, 91.1-100%), specificity of 100% (95% CI, 93.7-100%), positive predictive value of 100%, and negative predictive value of 98.3% (95% CI, 89.1-100%). Accuracy was 99.1% (95% CI, 95.3-100%). CONCLUSION. Incorporating cone-beam CT into routine clinical practice as part of a standardized diagnostic algorithm yielded a 50% fracture detection rate in patients with negative wrist radiographs but ongoing clinical concern for radiocarpal fracture. Cone-beam CT provides more diagnostic information than radiographs at a lower radiation dose than conventional MDCT. Given the poor accuracy of radiographs for acute radiocarpal fractures and the high fracture prevalence in this cohort, we feel that cone-beam CT should be regarded as the new standard of care in the investigation of these patients.