腕关节体检对三角纤维软骨复合体损伤的诊断价值

Value of conventional wrist physical examination in detection of injury to triangular fibrocartilage complex

目的探讨常用于诊断三角纤维软骨复合体(TFCC)损伤的体检方法在诊断TFCC损伤时的应用价值,以期为术前诊断较困难的边缘型损伤提供更可靠的体检策略。方法回顾性分析2013年1月至2017年10月北京积水潭医院手外科收治且拟行腕关节镜下手术的118例(119例腕关节)患者资料。男68例,女50例;平均年龄32岁。术前进行详细体格检查(包括尺侧小凹征、琴键征、尺骨远端位移试验和尺腕应力试验),并将查体结果和关节镜术中确诊的TFCC损伤情况进行对比,分别得出每项待检试验的敏感性、特异性、阳性/阴性预测值、阳性/阴性似然比等评价指标。同时将体检方法中针对边缘型损伤的3个待检试验(尺侧小凹征、琴键征和尺骨远端位移试验)进行两两组合,得出诊断价值最高的组合。结果尺侧小凹征、琴键征、尺骨远端位移试验和尺腕应力试验敏感性分别为0.648、0.817、0.927、0.825,特异性分别为0.742、0.735、0.647、0.500。将针对边缘型损伤的上述前3项体检结果两两组合后,得到3项新的待检试验,其中诊断价值最高的组合为尺侧小凹征+尺骨远端位移试验:敏感性0.598,特异性0.941,阳性预测值0.961,阳性似然比10.140。结论临床上常用于诊断TFCC损伤的体检方法在诊断过程中具有一定的参考价值,但单独一项查体结果的准确性并不高。当把尺侧小凹征和尺骨远端位移试验的结果联合起来,可以获得较高的特异性与阳性预测值,这对指导临床诊治工作具有重要的临床意义。

Objective To evaluate conventional wrist physical examination in detecting injury to the triangular fibrocartilage complex (TFCC). Methods A retrospective study was conducted of the 118 patients (119 wrists) who had been admitted from January 2013 to October 2017 to Hand Surgery Department,Beijing Jishuitan Hospital for wrist arthroscopic surgery.All of them underwent wrist physical examination preoperatively for conventional index tests for TFCC injury like ulnar fovea sign,piano-key test,distal ulnar ballottement test and ulnocarpal stress test.They were 68 males and 50 females with a mean age of 32 years.The results of physical examination were compared with the arthroscopic findings to calculate the sensitivity,specificity,positive/negative predictive value (PPV/NPV) and+/- likelihood ratio (LR) of each index test.In addition,we combined the results of any 2 tests to increase the capability of detecting peripheral TFCC injury. Results The diagnostic values of each index test were achieved by comparison between the results of physical examination and the arthroscopic findings: (1) ulnar fovea sign: sensitivity=0.648,specificity=0.742;(2) piano key test: sensitivity=0.817,specificity=0.735;(3) distal ulnar ballottement test: sensitivity =0.927,specificity=0.647;(4) ulnocarpal stress test: sensitivity=0.825,specificity=0.500.The combination of any 2 tests produced 3 new index tests,of which the most valuable combination was ulnar fovea sign & distal ulna ballottement test,with a sensitivity of 0.598,a specificity of 0.941,a PPV of 0.961 and a +LR of 10.14, Conclusions The signs elicited in physical examination and special tests can be helpful in the diagnosis of TFCC injuries.However,as the value of any single test is not enough,we should clinically combine the results of ulna fovea sign and distal ulna ballottement test to increase the capability of detecting peripheral TFCC injury.