Early MRI versus conventional management in the detection of occult scaphoid fractures: what does it really cost? A rural pilot study

Abstract

IntroductionTo compare the cost‐effectiveness and patient impact between acute magnetic resonance imaging (MRI) management and conventional management in the diagnosis of occult scaphoid fractures in a rural setting.MethodsConsecutive patients presenting to a rural emergency department (ED) with a suspected scaphoid fracture were randomly assigned to either conventional management (6) or acute MRI management (10) (3 patients were excluded from the study analysis). All healthcare costs were compared between the two management groups and potential impacts on the patients’ pain, mobility and lifestyle were also measured.ResultsThere were no significant differences between the two groups at baseline. There was one (10%) scaphoid fracture in the MRI group and none in the conventional group (P = 0.42). A larger proportion of other fractures were diagnosed in the MRI group (20% (2) vs. 16.7% (1), P = 0.87), as well as less clinic attendances (1 (0–2.25) vs. 4 (2.25–5)) and diagnostic services (1 (1–1.25) vs. 2 (1–3)). Median management costs were $485.05 (AUD) (MRI) and $486.90 (AUD) (conventional). The MRI group had better pain and satisfaction scores as well as less time of immobilisation, treatment and time off work.Conclusion MRI dramatically reduces the amount of unnecessary immobilisation, time of treatment and healthcare usage in a rural setting. The two protocols are suggested to be equivalent financially. When potential societal costs, the amount of unnecessary immobilisation, low prevalence of true fractures and patient satisfaction are considered, acute MRI should be the management technique of choice. Further studies are still required to assess the best method for managing bone bruise within the scaphoid.

The utility of cross‐sectional imaging in the management of suspected scaphoid fractures

“…However, the true cost to the patient and the healthcare system likely outweighs these small differences in imaging cost. Despite an X‐ray being cheaper than a CT or MRI, multiple studies have found that there is either no significant difference in cost or that serial radiographic surveillance is less cost effective than CT or MRI, and that MRI is overall more cost‐effective than CT due to its higher sensitivity . Patient productivity is a major issue with prolonged unnecessary immobilisation of clinically suspected scaphoid fractures, since immobilising scaphoid casts make working difficult, forcing patients to take leave from work and lose wages.…”

Review article: Best practice management of closed hand and wrist injuries in the emergency department (part 5 of the musculoskeletal injuries rapid review series)

“…This review identified recent and consistent evidence to support the early use of MRI for suspected scaphoid fractures, as earlier confirmation of diagnosis contributes to reduced immobilisation time, healthcare utilisation and costs . An Australian pilot study in a regional ED setting supported these results, indicating that MRI within 1–3 days following the ED presentation dramatically reduced unnecessary immobilisation and time off work, time of treatment and healthcare usage in their setting, with better patient pain and satisfaction scores than controls . The early use of MRI for suspected scaphoid fractures is further supported in the Western Australian diagnostic imaging pathway .…”

“…15,34,55,58,59,61 An Australian pilot study in a regional ED setting supported these results, indicating that MRI within 1-3 days following the ED presentation dramatically reduced unnecessary immobilisation and time off work, time of treatment and healthcare usage in their setting, with better patient pain and satisfaction scores than controls. 69 The early use of MRI for suspected scaphoid fractures is further supported in the Western Australian diagnostic imaging pathway. 70 Anecdotally, the referral of patients with a high clinical suspicion of scaphoid fracture for early MRI is often undertaken at follow up rather than in the ED and may represent an area for practice change.…”

Value of MRI in medicine: More than just another test?

“…Rapid protocols in musculoskeletal (MSK) MRI have been used to rule out occult fractures of the hip and wrist in the emergency setting. [27][28][29] When negative, MRI can exclude a fracture with rapidity and certainty, avoiding further testing. When positive, MR can lead to rapid treatment, avoiding complications.…”