Musculoskeletal injuries are among the most common causes of morbidity and disability following trauma, particularly in developing countries like India. The high incidence of road traffic accidents, falls, and occupational injuries makes trauma a significant public health issue in regions such as Varanasi, Uttar Pradesh. Accurate and timely diagnosis of these injuries is crucial for effective treatment and optimal recovery. Imaging modalities such as X-ray and Magnetic Resonance Imaging (MRI) play a pivotal role in the assessment and diagnosis of musculoskeletal trauma, helping to identify fractures, dislocations, ligament tears, and soft tissue damage that might otherwise go undetected.^1-3

X-ray imaging, due to its widespread availability, affordability, and speed, remains the first-line diagnostic tool in most trauma cases. It is particularly effective for visualizing bone fractures and dislocations. However, X-rays have limitations in assessing soft tissue injuries and subtle fractures. MRI, on the other hand, is a more advanced imaging technique that provides detailed visualization of both bone and soft tissues, including muscles, tendons, ligaments, and cartilage. MRI is especially useful in diagnosing injuries that may not be apparent on X-rays, such as ligament tears, bone marrow edema, and other soft tissue injuries, offering a more comprehensive evaluation of musculoskeletal trauma.^4,5

Despite the critical role of imaging in the diagnosis of musculoskeletal injuries, the patterns of injuries diagnosed through X-ray and MRI in trauma patients in Varanasi have not been thoroughly studied. Understanding these patterns is essential for clinicians to make informed decisions regarding the most appropriate imaging modality based on the type and severity of injury. This knowledge can also guide resource allocation, improving patient outcomes by ensuring the timely and accurate diagnosis of injuries.^6-8

This study aims to examine the patterns of musculoskeletal injuries diagnosed through X-ray and MRI in trauma patients in Varanasi, Uttar Pradesh. By comparing the diagnostic capabilities of these two imaging modalities, this research seeks to provide insights into their respective roles in trauma care and highlight the types of injuries where MRI offers significant advantages over X-ray. Ultimately, the findings of this study will contribute to the optimization of diagnostic protocols in trauma care settings, enhancing the overall quality of patient management in the region.

Aims and Objectives

Aims:

The primary aim of this study is to analyze and compare the patterns of musculoskeletal injuries diagnosed through X-ray and Magnetic Resonance Imaging (MRI) in trauma patients in Varanasi, Uttar Pradesh. The study seeks to identify the most common types of injuries observed and evaluate the diagnostic effectiveness of both imaging modalities in detecting different types of musculoskeletal trauma.

Objectives:

1. To assess the prevalence and types of musculoskeletal injuries diagnosed using X-ray and MRI in trauma patients presenting at healthcare facilities in Varanasi, Uttar Pradesh.
2. To compare the diagnostic accuracy and utility of X-ray and MRI in identifying bone fractures, dislocations, ligament injuries, and soft tissue damage in trauma patients.
3. To determine the role of MRI in cases where X-ray fails to provide sufficient information for an accurate diagnosis, particularly in detecting soft tissue injuries and subtle fractures.
4. To provide insights into the strengths and limitations of both imaging modalities and offer recommendations for the optimal use of X-ray and MRI in trauma care protocols.
5. To contribute to the development of diagnostic guidelines for musculoskeletal injuries in trauma patients that could improve patient outcomes and resource allocation in healthcare settings.

Study Design: This was a prospective observational study conducted on trauma patients who presented with musculoskeletal injuries at selected hospitals and diagnostic centers in Varanasi, Uttar Pradesh. The study involved the use of both X-ray and MRI to diagnose musculoskeletal injuries in patients who had sustained trauma from road traffic accidents, falls, sports injuries, or occupational hazards.

Study Population:

• Inclusion Criteria:
• Trauma patients aged 18 years and above.
• Patients presenting with suspected musculoskeletal injuries due to acute trauma.
• Patients who had undergone both X-ray and MRI imaging as part of their diagnostic evaluation.
• Exclusion Criteria:
• Patients with pre-existing musculoskeletal conditions or deformities.
• Patients unable to undergo MRI due to contraindications (e.g., presence of metallic implants or severe claustrophobia).
• Pediatric patients below the age of 18.

Sample Size: A sample size of approximately 200 patients was selected based on convenience sampling from trauma patients visiting selected hospitals and diagnostic centers over a period of 6 months.

Data Collection:

1. Patient Demographics: Data on age, gender, type of trauma (e.g., road traffic accident, fall, sports injury), and injury site were recorded.
2. Imaging Data:
• All patients underwent standard X-ray imaging as the initial diagnostic tool.
• Subsequently, patients underwent MRI based on the treating physician’s recommendation or when the X-ray results were inconclusive, especially in cases of suspected soft tissue injury or complex fractures.
3. Injury Patterns: The types of injuries diagnosed by both X-ray and MRI were documented, including fractures, dislocations, ligament tears, tendon injuries, and bone marrow abnormalities.

Imaging Protocol:

• X-ray: Standard radiographic views (anteroposterior, lateral, and oblique) were taken based on the injury site (e.g., extremities, spine, pelvis).
• MRI: MRI was performed using high-field (1.5 Tesla or 3 Tesla) machines, with protocols adapted to visualize bones, soft tissues, and joints, including T1, T2, and fat-suppressed sequences.

Outcome Measures:

1. Primary Outcome: The number and types of musculoskeletal injuries diagnosed by X-ray and MRI.
2. Secondary Outcome: The diagnostic accuracy of X-ray compared to MRI in detecting various types of musculoskeletal injuries, particularly in cases of soft tissue damage and subtle fractures.

Data Analysis:

• Descriptive Statistics: Demographic and injury data were analyzed using mean, median, and percentage distributions.
• Comparative Analysis: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of X-ray compared to MRI were calculated. The McNemar test was used to determine the statistical significance of differences in diagnostic accuracy between the two modalities.
• Software: Data were analyzed using SPSS version 25.0 or similar statistical software.

The study included 200 trauma patients, with a male predominance of 64% (128 males) compared to 36% (72 females). The patients were categorized into four age groups, with the majority falling in the 31-45 years age range (33%, n=66), followed by the 46-60 years group (29%, n=58), and the 18-30 years group (23.5%, n=47). Only 14.5% (n=29) of the patients were above 61 years of age. In terms of the mechanism of injury, road traffic accidents accounted for nearly half (49%, n=98) of the cases, followed by falls (33.5%, n=67), sports-related injuries (11.5%, n=23), and occupational injuries (6%, n=12). These demographics reflect the high incidence of trauma among active, working-age individuals, particularly men, and the significant role of road traffic accidents in musculoskeletal injuries.

Figure-1: Demographic Profile of Trauma Patients (N=200)

A comparison of the diagnostic yield of X-ray and MRI revealed that X-ray successfully detected 142 bone fractures, while MRI detected 163 fractures, including subtle fractures that were missed by X-ray. In the case of dislocations, both modalities identified 32 dislocations. However, X-ray failed to diagnose any soft tissue injuries, while MRI was able to detect 61 ligament tears, 48 tendon injuries, and 46 cases of soft tissue contusions. MRI also identified 24 cases of bone marrow edema, which were completely undetected by X-ray. These results underscore the superior ability of MRI to detect soft tissue injuries and subtle bone injuries that X-ray cannot visualize.

Table 1: Types of Injuries Diagnosed by X-ray and MRI

A more detailed analysis of fracture detection by location revealed that X-ray diagnosed 53 upper limb fractures, compared to 57 diagnosed by MRI. In lower limb fractures, X-ray identified 83 cases, while MRI found 89. MRI detected subtle fractures that were missed by X-ray in 4 upper limb cases and 6 lower limb cases. For pelvic and spinal fractures, both modalities detected 22 fractures. MRI identified a small number of fractures (n=2) in other body regions that were not visible on X-ray. This indicates that while X-ray is quite effective at identifying most fractures, MRI can detect additional cases, particularly in complex or subtle fractures.

Table 2: Comparison of X-ray and MRI in Detecting Fractures (N=163)

In terms of soft tissue injuries, X-ray did not detect any ligament tears, tendon injuries, or soft tissue contusions. However, MRI identified 61 cases of ligament tears, 48 tendon injuries, and 46 soft tissue contusions, all of which were completely missed by X-ray. This highlights the limitations of X-ray in evaluating soft tissue structures and the indispensable role of MRI in providing a comprehensive diagnosis of trauma-related injuries, particularly when soft tissue damage is suspected.

Table 3: Comparison of X-ray and MRI in Soft Tissue Injury Detection (N=85)

The sensitivity of X-ray for detecting bone fractures was found to be 89.7%, while MRI achieved a sensitivity of 100%, making MRI the gold standard for fracture detection. Both X-ray and MRI had a perfect specificity of 100% for dislocations. However, X-ray had no sensitivity in detecting ligament tears, tendon injuries, or soft tissue injuries, whereas MRI had a sensitivity of 100% in these categories. This clearly illustrates that while X-ray is a valuable tool for diagnosing bone-related injuries, its diagnostic capability is significantly inferior to MRI when it comes to soft tissue damage.

Table 4: Diagnostic Accuracy of X-ray vs. MRI for Musculoskeletal Injuries

Among the 85 patients who had normal X-ray results but underwent MRI due to persistent clinical suspicion, MRI identified a substantial number of injuries that were missed by X-ray. Specifically, 61 cases of ligament tears (71.8%), 48 cases of tendon injuries (56.5%), 24 cases of bone marrow edema (28.2%), and 46 cases of soft tissue contusions (54.1%) were diagnosed through MRI. These findings emphasize the importance of MRI in cases where X-ray results are inconclusive or normal, as it often reveals underlying soft tissue injuries and subtle bone damage that can be crucial for appropriate treatment planning.

Figure-2: Summary of MRI Findings in Patients with Normal X-ray Results (N=85)

Figure-3(a-d): Patterns of Musculoskeletal Injuries Diagnosed through X-ray and MRI in Trauma Patients

The present study highlights the critical role of advanced imaging techniques, particularly MRI, in the accurate diagnosis of musculoskeletal injuries in trauma patients in Varanasi, Uttar Pradesh. The findings demonstrate that while X-ray remains an essential and widely used diagnostic tool for bone fractures and dislocations, its limitations become evident when assessing soft tissue injuries and subtle bone abnormalities. MRI, with its superior ability to visualize both bone and soft tissue structures, emerges as an indispensable complement to X-ray in the comprehensive evaluation of musculoskeletal trauma. The demographic profile of patients in this study revealed that a significant portion of trauma cases involved males (64%), with the highest prevalence of injuries occurring in individuals between the ages of 31 and 45 years. This age group is typically the most active and involved in road traffic accidents or occupational injuries, which accounted for nearly half of all trauma cases. This finding aligns with previous studies in similar settings, which have consistently shown that men in their working years are disproportionately affected by trauma, largely due to high-risk behaviors such as driving and engaging in physically demanding occupations.^9,10 Road traffic accidents were the most common cause of injury (49%), reinforcing the need for targeted public health interventions to address road safety in this region.

One of the most significant findings of this study is the discrepancy between the diagnostic capabilities of X-ray and MRI. While X-ray successfully identified 142 bone fractures, MRI detected 163, revealing additional subtle fractures that were missed by X-ray. These findings underscore the limitations of X-ray in detecting subtle and complex fractures, particularly in areas such as the upper and lower limbs. In cases where fractures were initially missed by X-ray, MRI proved invaluable, detecting 10% more fractures. This suggests that reliance on X-ray alone, especially in high-risk cases, may lead to underdiagnosis of fractures, potentially resulting in inadequate treatment and poor patient outcomes.^4,11

Soft tissue injuries, which are a common consequence of trauma, were entirely missed by X-ray in this study. MRI, however, detected 61 cases of ligament tears, 48 cases of tendon injuries, and 46 soft tissue contusions. These findings highlight the crucial role of MRI in diagnosing soft tissue injuries that X-ray is unable to visualize. Previous research has similarly demonstrated that soft tissue injuries, including ligament and tendon damage, are often overlooked when X-ray is the sole imaging modality used. These types of injuries, if left undiagnosed, can lead to long-term functional impairment, chronic pain, and disability. The early detection of these injuries via MRI ensures timely and appropriate intervention, which can significantly improve patient outcomes.^12,13

The diagnostic accuracy of X-ray versus MRI for various types of musculoskeletal injuries further underscores the value of MRI. The sensitivity of X-ray for detecting bone fractures was 89.7%, which is acceptable for many trauma scenarios. However, its sensitivity for soft tissue injuries was 0%, indicating that X-ray alone is insufficient for comprehensive musculoskeletal injury assessment. In contrast, MRI achieved 100% sensitivity for fractures, ligament tears, tendon injuries, and soft tissue injuries. This finding supports the growing consensus in trauma care that MRI should be employed in cases where X-ray results are inconclusive or when there is a strong clinical suspicion of soft tissue damage.^14,15

Another important aspect revealed in this study is the high diagnostic yield of MRI in patients with normal X-ray results. Among the 85 patients who had normal X-ray findings but persistent clinical suspicion of injury, MRI identified a significant number of injuries, including 61 ligament tears, 48 tendon injuries, 24 cases of bone marrow edema, and 46 soft tissue contusions. This finding is clinically significant, as it demonstrates that a normal X-ray result does not rule out significant underlying injury. In these cases, MRI plays a pivotal role in preventing missed diagnoses and ensuring that patients receive the appropriate care.^15,16

The results of this study have several important clinical implications. First, they highlight the need for a more judicious use of MRI in trauma cases, particularly when X-ray results are inconclusive or when soft tissue injuries are suspected. Given the superior sensitivity and specificity of MRI, it should be considered the gold standard for comprehensive evaluation in trauma patients, especially in complex or ambiguous cases. Second, the findings suggest that relying solely on X-ray can lead to underdiagnosis, which can adversely affect patient outcomes, particularly in cases of soft tissue injury. Incorporating MRI into routine trauma care protocols, especially for patients with suspected ligament, tendon, or cartilage damage, can significantly improve diagnostic accuracy and treatment outcomes.^17,18

However, the study also acknowledges the limitations of widespread MRI use. MRI is more expensive, time-consuming, and less available than X-ray, particularly in resource-limited settings such as Varanasi. Therefore, the implementation of diagnostic protocols that incorporate MRI should consider these factors, ensuring that MRI is used selectively and in cases where X-ray fails to provide adequate diagnostic information. Future studies could focus on developing cost-effective strategies for integrating MRI into trauma care, particularly in low-resource settings, to balance diagnostic accuracy with financial and logistical constraints.^19,20

In conclusion, this study demonstrates the critical importance of MRI in the accurate diagnosis of musculoskeletal injuries in trauma patients. While X-ray remains a valuable first-line imaging tool, its limitations in detecting soft tissue injuries and subtle fractures necessitate the complementary use of MRI for a comprehensive diagnosis. The findings underscore the need for incorporating MRI into trauma care protocols, particularly in cases where X-ray results are inconclusive or where soft tissue injuries are suspected. By improving diagnostic accuracy, these practices can lead to better patient management, more effective treatment interventions, and ultimately, improved patient outcomes in trauma care.

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