qualitative evaluation of digital hand x-rays is not a reliable method to assess bone mineral density

object: 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.conclusion: 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.