title: Efficacy of Magnetic Resonance Imaging and Clinical Tests in Diagnostics of Wrist Ligament Injuries: A Systematic Review.
abstract: OBJECTIVE
  To investigate the diagnostic performance of magnetic resonance imaging (MRI) and clinical provocative tests on injuries to the triangular fibrocartilage complex (TFCC), the scapholunate (SL) ligament, and the lunotriquetral (LT) ligament.
  
  
  METHODS
  An electronic literature search of articles published between January 1, 2000, and February 28, 2014, in PubMed, Embase, and the Cochrane Library was carried out in April 2014. Only studies of the diagnostic performance of MRI and clinical provocation tests using wrist arthroscopy as the gold standard were eligible for inclusion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the extraction and reporting of data. The methodologic quality of the included articles was assessed with the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The primary outcome measure was the negative predictive value (NPV) of wrist MRI and provocative wrist tests, which was defined as the probability of an intact wrist ligament given a negative investigation. The question was whether negative results of MRI or provocative tests were enough to safely discontinue further investigation with arthroscopy. A minimum NPV of 95% was considered a clinically relevant cutoff value. The secondary outcome measures were the positive predictive value (PPV), sensitivity, and specificity.
  
  
  RESULTS
  A total of 7 articles (327 patients with MRI and 105 patients with clinical tests) were included in this systematic review. The included articles displayed heterogeneity regarding participants, diagnostic methods, and study design. Seven articles investigated the diagnostic performance of MRI, whereas 1 article investigated clinical testing. The NPVs of MRI were as follows: TFCC, 37% to 90%; SL ligament, 72% to 94%; and LT ligament, 74% to 95%. The NPVs of clinical tests were 55%, 74%, and 94% for the TFCC, SL ligament, and LT ligament, respectively. Only 1 study reached the predetermined cutoff value for the primary outcome measure (NPV ≥95%) but only for MRI of the LT ligament; this study also reached a borderline-cutoff NPV of 94% for MRI of the SL ligament. Another study reached borderline-cutoff NPVs of 94% both for MRI and for clinical tests of the LT ligament.
  
  
  CONCLUSIONS
  A negative result from MRI is unable to rule out the possibility of a clinically relevant injury to the TFCC, SL ligament, or LT ligament of the wrist. Clinical provocation wrist tests were of limited diagnostic value. The current gold standard--wrist arthroscopy--remains the preferred diagnostic technique with sufficient conclusive properties when it comes to wrist ligament injuries.
  
  
  METHODS
  Level II, systematic review of Level II diagnostic studies.
authors.affiliation: Department of Hand Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Electronic address: jonny_a@telia.com.
authors.forename: Jonny K
authors.initials: JK
authors.lastname: Andersson
authors.affiliation: Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Vårdcentralen Gripen, Karlstad, Sweden; Primary Care Research Unit, Centre for Clinical Research, County Council of Värmland, Karlstad, Sweden.
authors.forename: Daniel
authors.initials: D
authors.lastname: Andernord
authors.affiliation: Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
authors.forename: Jón
authors.initials: J
authors.lastname: Karlsson
authors.affiliation: Department of Hand Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden.
authors.forename: Jan
authors.initials: J
authors.lastname: Fridén
mesh_terms: D001182:Arthroscopy / Q000379:methods / Q000592:standards; D006801:Humans; D008023:Ligaments, Articular / Q000293:injuries*; D012667:Lunate Bone; D008279:Magnetic Resonance Imaging / Q000379:methods*; D021361:Scaphoid Bone; D012680:Sensitivity and Specificity; D051478:Triangular Fibrocartilage / Q000293:injuries*; D051221:Triquetrum Bone; D014954:Wrist Injuries / Q000175:diagnosis*