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Research ArticleOriginal Research

Improving Effective Magnetic Resonance Imaging (MRI) Application in Soft Tissue Wrist Injury

Alfred P. Yoon, Alexandra L. Mathews, Helen E. Huetteman, Brett F. Michelotti and Kevin C. Chung
The Journal of the American Board of Family Medicine September 2018, 31 (5) 795-804; DOI: https://doi.org/10.3122/jabfm.2018.05.170423
Alfred P. Yoon
From the Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School, Ann Arbor (APY, HEH); Stritch School of Medicine, Loyola University, Chicago, IL (ALM); Department of Surgery, Division of Plastic Surgery, University of Wisconsin Health System, Madison, WI (BFM); Section of Plastic Surgery, Assistant Dean for Faculty Affairs, The University of Michigan Medical School, Ann Arbor (KCC).
MD
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Alexandra L. Mathews
From the Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School, Ann Arbor (APY, HEH); Stritch School of Medicine, Loyola University, Chicago, IL (ALM); Department of Surgery, Division of Plastic Surgery, University of Wisconsin Health System, Madison, WI (BFM); Section of Plastic Surgery, Assistant Dean for Faculty Affairs, The University of Michigan Medical School, Ann Arbor (KCC).
BS
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Helen E. Huetteman
From the Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School, Ann Arbor (APY, HEH); Stritch School of Medicine, Loyola University, Chicago, IL (ALM); Department of Surgery, Division of Plastic Surgery, University of Wisconsin Health System, Madison, WI (BFM); Section of Plastic Surgery, Assistant Dean for Faculty Affairs, The University of Michigan Medical School, Ann Arbor (KCC).
BS
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Brett F. Michelotti
From the Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School, Ann Arbor (APY, HEH); Stritch School of Medicine, Loyola University, Chicago, IL (ALM); Department of Surgery, Division of Plastic Surgery, University of Wisconsin Health System, Madison, WI (BFM); Section of Plastic Surgery, Assistant Dean for Faculty Affairs, The University of Michigan Medical School, Ann Arbor (KCC).
MD
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Kevin C. Chung
From the Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School, Ann Arbor (APY, HEH); Stritch School of Medicine, Loyola University, Chicago, IL (ALM); Department of Surgery, Division of Plastic Surgery, University of Wisconsin Health System, Madison, WI (BFM); Section of Plastic Surgery, Assistant Dean for Faculty Affairs, The University of Michigan Medical School, Ann Arbor (KCC).
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    Figure 1.

    Flowchart of Cohort Selection. MRI, magnetic resonance imaging.

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    Table 1.

    Baseline Demographics of Patients

    All PatientsImpact MRI GroupNon-Impact MRI GroupP-Value
    Number of patients1403928%10172%
    Age3733(30–37)*39(36–41)*.01†‡
    Gender
        Male5338%1439.85§
        Female8762%2562
    BMI28.228.227.8.86†
    Obesity4834%1333%3535%1.00§
    Smokers2115%718%1414%.60§
    Referring provider
        UMHS12287%3385%9988%.56§
        Non-UMHS1813%615%1212%
    Previous hand surgery/trauma4129%1026%3131%.68§
    Charlson Comorbidity Index0.310.180.36.15§
    Prior therapy/splinting/injections8762%2154%6665%.25§
    Insured in healthcare13395%3795%9695%1.00§
    MRI timing (<6 weeks of symptoms)4834%1949%2929%.03*§
    • BMI, body mass index; MRI, magnetic resonance imaging; UMHS, University of Michigan Health System.

    • ↵* 95% confidence interval (CI).

    • ↵† Student t-test.

    • ↵‡ Statistical significance.

    • ↵§ Fisher exact test.

    • View popup
    Table 2.

    Comparison of Impact vs Nonimpact MRI

    VariableImpact MRINonimpact MRIP-Values
    Total patients3928%10172%
    Ordering physician
        Hand surgeon2667%4040%.0048*†
        Referring physician1333%6160%
    Study indication
        Wrist pain1128%6064%.0012*†
        Question of specific injury2872%4136%
        DRUJ stability21
        Scapholunate injury177
        TFCC injury312
        Other ligamentous injury621
    • DRUJ, distal radioulnar joint; MRI, magnetic resonance imaging; TFCC, triangular fibrocartilage complex.

    • ↵* Fisher exact test.

    • ↵† Statistical significance.

    • View popup
    Table 3.

    Baseline Demographics Comparison between Hand Surgeon and Referring Physician Patient Cohorts

    Hand Surgeon GroupReferring Physician GroupP-Value
    Number of patients6674
    Age3638.15*
    Gender
        Male2233%3142%.39†
        Female4467%4358%
    BMI28.827.9.47*
    Obesity2436%2432%.60†
    Smokers914%1216%.81†
    Referring provider
        UMHS11285%6689%.61†
        Non-UMHS1015%811%
    Previous hand surgery/trauma2741%1419%.005†‡
    Charlson Comorbidity Index0.240.36.24*
    Prior therapy/splinting/injections4467%4358%.38†
    Insured in healthcare6294%7196%.71†
    MRI timing (<6weeks of symptoms)2741%2128%.15†
    • BMI, body mass index; MRI, magnetic resonance imaging; UMHS, University of Michigan Health System.

    • ↵* Student t-test.

    • ↵† Fisher exact test.

    • ↵‡ Statistical significance.

    • View popup
    Table 4.

    Comparison of MRI Indications Ordered by Hand Surgeons and Referring Physicians

    VariablesHand Surgeon MRIReferring Physician MRIP-Values
    Total patients6647%7453%
    Study indication
    Wrist pain2335%4865%.0006*†
    Question of specific injury4365%2635%
    DRUJ stability30
    Scapholunate injury204
    TFCC injury78
    Other ligamentous injury1314
    • DRUJ, distal radioulnar joint; MRI, magnetic resonance imaging; TFCC, triangular fibrocartilage complex.

    • ↵* Statistical significance.

    • ↵† Fisher exact test.

    • View popup
    Table 5.

    Pre-MRI to Post-MRI Recommendation Changes in Impact and Non-Impact MRI Studies

    Pre/Post MRI RecommendationsAll PatientsHand Surgeon Cohort PatientsReferring Physician Cohort PatientsP-Values
    Impact MRI392613
        Non-op → Op10415%646%.056*
        Op → Non-op000%00%1.00
        Eq → Non-op191558%431%.18
        Eq → Op10727%323%1.00
        Op → Eq000%00%1.00
        Non-op → Eq000%00%1.00
    Nonimpact MRI1014061
        Non-op → Non-op752050%5590%<.001*
        Op → Op211640%58%.20
        Eq → Eq5410%12%.08
    • Eq, equivocal; MRI, magnetic resonance imaging; Non-op, non-operative; Op, operative.

    • ↵* Statistical significance.

    • View popup
    Table 6.

    Multivariate Regression of Predictive Factors to Impact MRI

    Adjusted OR95% CIP-Values
    Age0.97(0.93–1.00).067
    MRI Timing (<6 weeks of symptoms)2.59(1.12–5.99).026*
    Study indication: No specific diagnosis0.39(0.16–0.94).036*
    Referring physician0.43(0.18–1.00).052*
    • CI, confidential interval; MRI, magnetic resonance imaging; OR, odd ratio.

    • ↵* Statistical significance.

    • View popup
    Appendix
    ICD-9 CodeDescription
    719.43 to 719.44Wrist pain
    728.4Laxity of ligament
    833.01DRUJ Instability (closed)
    833.11DRUJ Instability (open)
    842.00Sprain of wrist, unspecified site
    842.01Sprains and strains wrist and hand; wrist; carpal (joint)
    842.02Sprain of radiocarpal (ligament) of wrist
    842.09Sprains and strains of wrist and hand; distal radioulnar joint
    905.7Late effect of sprain and strain without mention of tendon injury
    959.3Other and unspecified injury to elbow forearm and wrist
    • ICD-9, International Classification of Disease, version 9.

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The Journal of the American Board of Family     Medicine: 31 (5)
The Journal of the American Board of Family Medicine
Vol. 31, Issue 5
September-October 2018
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Improving Effective Magnetic Resonance Imaging (MRI) Application in Soft Tissue Wrist Injury
Alfred P. Yoon, Alexandra L. Mathews, Helen E. Huetteman, Brett F. Michelotti, Kevin C. Chung
The Journal of the American Board of Family Medicine Sep 2018, 31 (5) 795-804; DOI: 10.3122/jabfm.2018.05.170423

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Improving Effective Magnetic Resonance Imaging (MRI) Application in Soft Tissue Wrist Injury
Alfred P. Yoon, Alexandra L. Mathews, Helen E. Huetteman, Brett F. Michelotti, Kevin C. Chung
The Journal of the American Board of Family Medicine Sep 2018, 31 (5) 795-804; DOI: 10.3122/jabfm.2018.05.170423
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Keywords

  • Differential Diagnosis
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