title: Qualitative Evaluation of Digital Hand X-rays Is Not a Reliable Method to Assess Bone Mineral Density.
abstract: BACKGROUND
  The gold standard for evaluating bone mineral density is dual energy x-ray absorptiometry (DEXA). Prior studies have shown poor reliability using analog wrist X-rays in diagnosing osteoporosis. Our goal was to investigate if there was improved diagnostic value to visual assessment of digital hand X-rays in osteoporosis screening. We hypothesized that similar to analog counterparts, digital hand X-rays have poor correlation and reliability in determining bone mineral density (BMD) relative to DEXA.
  
  
  METHODS
  We prospectively evaluated female patients older than 65 years who presented to our hand clinic with digital hand and wrist X-rays as part of their evaluation over six months. Patients who had a fracture and were without DEXA scans within the past two years were excluded. Five fellowship-trained hand surgeons, blinded to DEXA T-scores, evaluated the x-rays over two assessments separated by four weeks and classified them as osteoporotic, osteopenic, or normal BMD. Accuracy relative to DEXA T-score, interobserver and intraobserver rates were calculated.
  
  
  RESULTS
  Thirty four patients met the inclusion criteria and a total of 340 x-rays reviews were performed. The assessments were correct in 169 cases (49%) as compared to the DEXA T-scores. A mean weighted kappa coefficient of agreement between observers was 0.29 (range 0.02-0.41) reflecting a fair agreement. The first and second assessment for all five physicians was 0.46 (range 0.19-0.78) reflecting a moderate agreement. Grouping osteoporosis and osteopenia together compared to normal, the accuracy, interobserver and intraobserver rates increased to 63%, 0.42 and 0.54 respectively.
  
  
  CONCLUSIONS
  Abnormally low BMD is a common occurrence in patients treated for upper extremity disorders. There is poor accuracy relative to DEXA scan and only fair agreement in diagnosing osteoporosis using visual assessments of digital x-rays.
authors.affiliation: Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Miller
authors.affiliation: Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Jones
authors.affiliation: Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA.
authors.forename: Frederick
authors.initials: F
authors.lastname: Liss
authors.affiliation: Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA.
authors.forename: Jack
authors.initials: J
authors.lastname: Abboudi
authors.affiliation: Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA.
authors.forename: William
authors.initials: W
authors.lastname: Kirkpatrick
authors.affiliation: Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA.
authors.forename: Pedro
authors.initials: P
authors.lastname: Beredjiklian
keywords: DEXA scan; Digital x-ray; Osteoporosis; Qualitative assessment