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.